| Plan
Benefits
|
BC LIFE & HEALTH INSURANCE COMPANY
Freedom
Blue Plan I
(R9943 - 001)
- Medicare Health Plan
- Regional PPO
- Provides health and drug coverage
- Approved by Medicare
- There are approximately 3501-4000
physicians and providers in this plan's
network.
- California
|
KAISER
PERMANENTE
Kaiser Permanente Senior Advantage (H0524
- 003)
- Medicare Health Plan
- HMO
- Provides health and drug coverage
- Approved by Medicare
- There are approximately 3501-4000
physicians and providers in this plan's
network.
- Los Angeles, Orange & Ventura
Counties Plan
|
BC LIFE & HEALTH INSURANCE COMPANY
Freedom
Blue Plan II
(R9943 - 002)
- Medicare Health Plan
- Regional PPO
- Provides health and drug coverage
- Approved by Medicare
- There are approximately 3501-4000
physicians and providers in this plan's
network.
-
California
|
|
Freedom
Blue PPO Application 2007
Download
Application
|
|
|
Estimated
Annual Cost for People Age 65 - 69 in Very
Good health 1
|
$2,400 |
$2,850 |
$3,000 |
| Important
Information |
| 1 |
Premium
and Other Important Information
2 |
General
$0 monthly plan premium in addition
to your $93.50 monthly Medicare Part
B premium.
In-Network
$3000 out-of-pocket limit every year
for benefits.
Out-of-Network
Contact the plan for more details on what
is covered out of network.
In
and Out-of-Network
$1000
yearly deductible for all benefits. This
deductible applies to benefits you get in-network
or out of network.
Yearly deductible applies to the following
benefits:
- Inpatient Hospital Care
- Inpatient Mental Health Care
- Skilled Nursing Facility
- Home Health Care
- Chiropractic Services
- Podiatry Services
- Outpatient Mental Health Care
- Outpatient Substance Abuse Care
- Outpatient Services/Surgery
- Ambulance Services
- Outpatient Rehabilitation Services
- Durable Medical Equipment
- Prosthetic Devices
- Diabetes Self-Monitoring Training
and Supplies
- Diagnostic Tests, X-Rays, and Lab
Services
- Hearing Services
- Transportation
- Comprehensive Outpatient Rehabilitation
Facility (CORF)
- Partial Hospitalization
- Other Health Care Professional
- Cardiac Rehabilitation Services
- Renal Dialysis
- Blood
- Medicare Part B Rx Drugs
|
General
$0 monthly plan premium in addition
to your $93.50 monthly Medicare Part
B premium.
In-Network
$4000 out-of-pocket limit every year
for certain plan benefits.
Out-of-pocket limit applies to the following
benefits:
- Inpatient Hospital Care
- Inpatient Mental Health Care
- Skilled Nursing Facility
- Home Health Care
- Doctor Office Visits
- Podiatry Services
- Outpatient Mental Health Care
- Outpatient Substance Abuse Care
- Outpatient Services/Surgery
- Ambulance Services
- Emergency Care
- Urgently Needed Care
- Outpatient Rehabilitation Services
- Diagnostic Tests, X-Rays, and Lab
Services
- Bone Mass Measurement
- Colorectal Screening Exam
- Mammograms (Annual Screenings)
- Pap Smears and Pelvic Exams
- Prostate Cancer Screening Exams
- Hearing Services
- Vision Services
- Physical Exams
- Health/Wellness Education
- Other Health Care Professional
- Cardiac Rehabilitation Services
- Renal Dialysis
Out-of-Network
Unless otherwise noted, out-of-network services
not covered.
|
General
$50 monthly plan premium in addition
to your $93.50 monthly Medicare Part
B premium.
In-Network
$3000 out-of-pocket limit every year
for benefits.
Out-of-Network
Contact the plan for more details on what
is covered out of network.
In
and Out-of-Network
$500 yearly
deductible for all benefits. This deductible
applies to benefits you get in-network or
out of network.
Yearly deductible applies to the following
benefits:
- Inpatient Hospital Care
- Inpatient Mental Health Care
- Skilled Nursing Facility
- Home Health Care
- Chiropractic Services
- Podiatry Services
- Outpatient Mental Health Care
- Outpatient Substance Abuse Care
- Outpatient Services/Surgery
- Ambulance Services
- Outpatient Rehabilitation Services
- Durable Medical Equipment
- Prosthetic Devices
- Diabetes Self-Monitoring Training
and Supplies
- Diagnostic Tests, X-Rays, and Lab
Services
- Hearing Services
- Transportation
- Comprehensive Outpatient Rehabilitation
Facility (CORF)
- Partial Hospitalization
- Other Health Care Professional
- Cardiac Rehabilitation Services
- Renal Dialysis
- Blood
- Medicare Part B Rx Drugs
|
| 2 |
Doctor
and Hospital Choice |
In-Network
No referral required for network doctors,
specialists, and hospitals.
You may have to pay a separate copay for
certain doctor office visits.
In
and Out-of-Network
You can go to doctors, specialists, and
hospitals in or out of the network. It will
cost more to get out of network benefits.
|
In-Network
You must go to network doctors, specialists,
and hospitals.
Referral required for network hospitals
and specialists (for certain benefits).
You may have to pay a separate copay for
certain doctor office visits.
Out-of-Network
Plan covers you when you travel in the U.S.
|
In-Network
No referral required for network doctors,
specialists, and hospitals.
You may have to pay a separate copay for
certain doctor office visits.
In
and Out-of-Network
You can go to doctors, specialists, and
hospitals in or out of the network. It will
cost more to get out of network benefits.
|
|
|
| Inpatient
Care |
| 3 |
Inpatient
Hospital Care |
In-Network
10 % of the cost for each Medicare-covered
hospital stay
$0 copay for additional
hospital days
No limit to the number of days covered by
the plan each benefit period.
Out-of-Network
10 % of the cost for each hospital
stay.
|
In-Network
$300 copay per day for days 1 - 10
in a Medicare-covered hospital.
For longer Medicare-covered hospital stays:
Days 11 - 90: $0 copay per day
Plan covers 60 life time reserve days. Cost
per lifetime reserve day:
Days 1 - 60: $0 copay per day
$0 copay for additional hospital
days
No limit to the number of days covered by
the plan each benefit period.
Except in an emergency, your doctor must
tell the plan that you are going to be admitted
to the hospital.
|
In-Network
10 % of the cost for each Medicare-covered
hospital stay
$0 copay for additional
hospital days
No limit to the number of days covered by
the plan each benefit period.
Out-of-Network
10 % of the cost for each hospital
stay.
|
|
|
| Outpatient
Care |
| 8 |
Doctor
Office Visits |
General
See Section 32, "Routine Physical Exams,"
for more information.
In-Network
$10 copay for each primary care doctor
visit for Medicare-covered benefits.
$10 copay for each specialist visit
for Medicare-covered benefits.
Out-of-Network
20 % for
each primary care doctor visit.
20
% for each specialist visit.
|
General
See Section 32, "Routine Physical Exams,"
for more information.
Authorization rules may apply.
In-Network
$20 copay for
each primary care doctor visit for Medicare-covered
benefits.
$20 copay for each
specialist visit for Medicare-covered benefits.
|
General
See Section 32, "Routine Physical Exams,"
for more information.
In-Network
$10 copay for each primary care doctor
visit for Medicare-covered benefits.
$10 copay for each specialist visit
for Medicare-covered benefits.
Out-of-Network
20 % for
each primary care doctor visit.
20
% for each specialist visit.
|
| 13 |
Outpatient
Services/Surgery |
In-Network
10 % of the cost for each Medicare-covered
ambulatory surgical center visit.
10
% of the cost for each Medicare-covered
outpatient hospital facility visit.
Out-of-Network
20 %
of the cost for ambulatory surgical center
benefits.
|
General
Authorization rules may apply.
In-Network
$250 copay
for each Medicare-covered ambulatory surgical
center visit.
$0 to $250
copay for each Medicare-covered outpatient
hospital facility visit.
|
In-Network
10 % of the cost for each Medicare-covered
ambulatory surgical center visit.
10
% of the cost for each Medicare-covered
outpatient hospital facility visit.
Out-of-Network
20 %
of the cost for ambulatory surgical center
benefits.
|
| 14 |
Ambulance
Services |
In-Network
10 % of the cost for Medicare-covered
ambulance benefits.
Out-of-Network
20 % of the cost for ambulance benefits.
|
General
Authorization rules may apply.
In-Network
$300 for Medicare-covered
ambulance benefits.
|
In-Network
10 % of the cost for Medicare-covered
ambulance benefits.
Out-of-Network
20 % of the cost for ambulance benefits.
|
|
|
| Outpatient
Medical Services and Supplies |
| 18 |
Durable
Medical Equipment |
In-Network
10 % of the cost for Medicare-covered
items.
Out-of-Network
20 % of the cost for durable medical
equipment.
|
General
Authorization rules may apply.
In-Network
20 % of the
cost for Medicare-covered items.
|
In-Network
10 % of the cost for Medicare-covered
items.
Out-of-Network
20 % of the cost for durable medical
equipment.
|
| 21 |
Diagnostic
Tests, X-Rays, and Lab Services |
In-Network
10 % of the cost for Medicare-covered
clinical/diagnostic lab benefits.
10
% of the cost for for Medicare-covered
radiation therapy benefits.
10 %
of the cost for Medicare-covered X-rays.
Out-of-Network
20 %
of the cost for clinical/diagnostic lab
benefits.
20 % of the cost for
radiation therapy benefits.
20 %
of the cost for X-rays.
|
General
Authorization rules may apply.
In-Network
$25 copay for
Medicare-covered clinical/diagnostic lab
benefits.
$0 copay for Medicare-covered
radiation therapy benefits.
$25
to $50 copay for Medicare-covered
X-rays.
|
In-Network
10 % of the cost for Medicare-covered
clinical/diagnostic lab benefits.
10
% of the cost for for Medicare-covered
radiation therapy benefits.
10 %
of the cost for Medicare-covered X-rays.
Out-of-Network
20 %
of the cost for clinical/diagnostic lab
benefits.
20 % of the cost for
radiation therapy benefits.
20 %
of the cost for X-rays.
|
|
|
| Additional
Benefits |
| 28 |
Prescription Drugs
Freedom
Blue PPO
Application
2007
Download
Application |
General
This plan uses a formulary. A formulary
is a list of drugs covered by the plan.
If a plan takes a drug off the list; changes
a drug on its list to a more expensive tier;
or places a prior authorization, step therapy
or quantity limit requirement on a drug,
the plan will tell you at least 60 days
before the change is effective. The plan
will send you the formulary. You can also
see the formulary at www.bluecrossca.com
on the web.
Different out-of-pocket costs may apply
for people who
- have limited incomes,
- live in long term care facilities,
or
- have access to Indian/Tribal/Urban
(Indian Health Service).
Some drugs have quantity limits.
In-Network
10 % of the
cost of Part B-covered drugs.
$0
deductible.
Your provider must get prior authorization
from Freedom Blue Plan I for certain drugs.
Some of the drugs covered by this plan do
not count toward your out-of-pocket expenses.
Initial Coverage
You pay the following until total yearly
drug costs reach $2400:
Retail Pharmacy
- $10 copay for a one-month (30-day)
supply of Generic drugs
- $30 copay for a one-month (30-day)
supply of Preferred Brand drugs
- $60 copay for a one-month (30-day)
supply of Non-Preferred Brand drugs
- 30 % coinsurance for a one-month
(30-day) supply of Non-Specialty Injectables
drugs
- 30 % coinsurance for a one-month
(30-day) supply of Specialty Injectables
drugs
- $30 copay for a three-month
(90-day) supply of Generic drugs
- $90 copay for a three-month
(90-day) supply of Preferred Brand drugs
- $180 copay for a three-month
(90-day) supply of Non-Preferred Brand
drugs
- 30 % coinsurance for a three-month
(90-day) supply of Non-Specialty Injectables
drugs
- 30 % coinsurance for a three-month
(90-day) supply of Specialty Injectables
drugs
Mail Order
- $15 copay for a three-month
(90-day) supply of Generic drugs from
a preferred mail order pharmacy.
- $75 copay for a three-month
(90-day) supply of Preferred Brand drugs
from a preferred mail order pharmacy.
- $150 copay for a three-month
(90-day) supply of Non-Preferred Brand
drugs from a preferred mail order pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Non-Specialty Injectables
drugs from a preferred mail order pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Specialty Injectables
drugs from a preferred mail order pharmacy.
- $30 copay for a three-month
(90-day) supply of Generic drugs from
a non-preferred mail order pharmacy.
- $90 copay for a three-month
(90-day) supply of Preferred Brand drugs
from a non-preferred mail order pharmacy.
- $180 copay for a three-month
(90-day) supply of Non-Preferred Brand
drugs from a non-preferred mail order
pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Non-Specialty Injectables
drugs from a non-preferred mail order
pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Specialty Injectables
drugs from a non-preferred mail order
pharmacy.
Gap Coverage
("donut hole")
You pay the following:
- $10 copay for a one-month (30-day)
supply of Generic drugs
- $30 copay for a three-month
(90-day) supply of Generic drugs
- $15 copay for a three-month
(90-day) supply of Generic drugs from
a preferred mail order
- $30 copay for a three-month
(90-day) supply of Generic drugs from
a non-preferred mail order
For all other covered drugs, after your
total yearly drug costs reach $2400,
you pay 100 % until your yearly
out-of-pocket drug costs reach $3850.
Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 3850, you pay the
greater of:
- $ 2.15 copay for generic
(including brand drugs treated as
generic) and $ 5.35 copay
for all other drugs, or
- 5 % coinsurance.
|
General
This plan uses a formulary. A formulary
is a list of drugs covered by the plan.
If a plan takes a drug off the list; changes
a drug on its list to a more expensive tier;
or places a prior authorization, step therapy
or quantity limit requirement on a drug,
the plan will tell you at least 60 days
before the change is effective. The plan
will send you the formulary. You can also
see the formulary at www.KaiserPermanente.org
on the web.
Different out-of-pocket costs may apply
for people who
- have limited incomes,
- live in long term care facilities,
or
- have access to Indian/Tribal/Urban
(Indian Health Service).
In-Network
$11
to $40 copay of Part B-covered drugs.
$0 deductible.
Initial
Coverage
You pay the following until total yearly
drug costs reach $2400:
Retail Pharmacy
- $11 copay for a one-month (30-day)
supply of Generic drugs
- $40 copay for a one-month (30-day)
supply of Brand-Name Drugs drugs
- $33 copay for a 100-day supply
of Generic drugs
- $120 copay for a 100-day supply
of Brand-Name Drugs drugs
Mail Order
- $11 copay for a one-month (30-day)
supply of Generic drugs
- $40 copay for a one-month (30-day)
supply of Brand-Name Drugs drugs
- $22 copay for a 100-day supply
of Generic drugs
- $80 copay for a 100-day supply
of Brand-Name Drugs drugs
Gap Coverage
("donut hole")
After
your total yearly drug costs reach $2400,
you pay 100 % until your yearly out-of-pocket
drug costs reach $3850.
Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $3850, you pay:
- $5 copay for Generic drugs
- $12 copay for Brand-Name Drugs
drugs
|
General
This plan uses a formulary. A formulary
is a list of drugs covered by the plan.
If a plan takes a drug off the list; changes
a drug on its list to a more expensive tier;
or places a prior authorization, step therapy
or quantity limit requirement on a drug,
the plan will tell you at least 60 days
before the change is effective. The plan
will send you the formulary. You can also
see the formulary at www.bluecrossca.com
on the web.
Different out-of-pocket costs may apply
for people who
- have limited incomes,
- live in long term care facilities,
or
- have access to Indian/Tribal/Urban
(Indian Health Service).
Some drugs have quantity limits.
In-Network
10 % of the
cost of Part B-covered drugs.
$0
deductible.
Your provider must get prior authorization
from Freedom Blue Plan II for certain drugs.
Some of the drugs covered by this plan do
not count toward your out-of-pocket expenses.
Initial Coverage
You pay the following until total yearly
drug costs reach $2400:
Retail Pharmacy
- $10 copay for a one-month (30-day)
supply of Generic drugs
- $30 copay for a one-month (30-day)
supply of Preferred Brand drugs
- $60 copay for a one-month (30-day)
supply of Non-Preferred Brand drugs
- 30 % coinsurance for a one-month
(30-day) supply of Non-Specialty Injectables
drugs
- 30 % coinsurance for a one-month
(30-day) supply of Specialty Injectables
drugs
- $30 copay for a three-month
(90-day) supply of Generic drugs
- $90 copay for a three-month
(90-day) supply of Preferred Brand drugs
- $180 copay for a three-month
(90-day) supply of Non-Preferred Brand
drugs
- 30 % coinsurance for a three-month
(90-day) supply of Non-Specialty Injectables
drugs
- 30 % coinsurance for a three-month
(90-day) supply of Specialty Injectables
drugs
Mail Order
- $15 copay for a three-month
(90-day) supply of Generic drugs from
a preferred mail order pharmacy.
- $75 copay for a three-month
(90-day) supply of Preferred Brand drugs
from a preferred mail order pharmacy.
- $150 copay for a three-month
(90-day) supply of Non-Preferred Brand
drugs from a preferred mail order pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Non-Specialty Injectables
drugs from a preferred mail order pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Specialty Injectables
drugs from a preferred mail order pharmacy.
- $30 copay for a three-month
(90-day) supply of Generic drugs from
a non-preferred mail order pharmacy.
- $90 copay for a three-month
(90-day) supply of Preferred Brand drugs
from a non-preferred mail order pharmacy.
- $180 copay for a three-month
(90-day) supply of Non-Preferred Brand
drugs from a non-preferred mail order
pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Non-Specialty Injectables
drugs from a non-preferred mail order
pharmacy.
- 25 % coinsurance for a three-month
(90-day) supply of Specialty Injectables
drugs from a non-preferred mail order
pharmacy.
Gap Coverage
("donut hole")
You pay the following:
- $10 copay for a one-month (30-day)
supply of Generic drugs
- $30 copay for a three-month
(90-day) supply of Generic drugs
- $15 copay for a three-month
(90-day) supply of Generic drugs from
a preferred mail order
- $30 copay for a three-month
(90-day) supply of Generic drugs from
a non-preferred mail order
For all other covered drugs, after your
total yearly drug costs reach $2400,
you pay 100 % until your yearly
out-of-pocket drug costs reach $3850.
Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 3850, you pay the
greater of:
- $ 2.15 copay for generic
(including brand drugs treated as
generic) and $ 5.35 copay
for all other drugs, or
- 5 % coinsurance.
|
| 29 |
Dental
Services |
In-Network
Preventive Dental Benefits:
In general, preventive dental benefits (such
as cleaning) not covered.
|
General
Authorization rules may apply.
In-Network
Preventive Dental Benefits:
In general, preventive dental benefits (such
as cleaning) not covered.
|
In-Network
Preventive Dental Benefits:
In general, preventive dental benefits (such
as cleaning) not covered.
|
