BlueCross BlueShield Forever Blue 751 (PPO) in Chautauqua, New York (2023)
BlueCross BlueShield Forever Blue 751 (PPO) in Chautauqua County, New York costs $204/mo. This affordable Regional PPO plan (H5526-004) is a top choice for those living in Chautauqua County with a $0 prescription deductible and out-of-pocket limits at $6,700. Learn more about Medicare Part C by AARP in Chautauqua County, New York below.
Read moreUPDATED: Sep 21, 2023
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UPDATED: Sep 21, 2023Fact Checked
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5 out of 5 stars* for plan year 2024
Plan ID: H5526-004
What You Need to Know:
- BlueCross BlueShield Forever Blue 751 (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
- It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
- It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
- The plan's monthly premium is $204, which does not include your monthly Medicare Part B premium.
- The annual deductible for this health plan is .
- The plan includes an out-of-pocket maximum of $6,700 per year (in-network).
- BlueCross BlueShield Forever Blue 751 (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
- This plan's Part D Initial Coverage Limit is $31.
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$204
Monthly Premium
| Medicare Plan Features | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Monthly Premium: | $204.00 | ||||||||
| Part C Premium: | $135.0 | ||||||||
| Monthly Premium: | Part C Premium: | Part D Drug Premium: | Part D Supplemental Premium: | Total Part D Premium: | Drug Deductible: | Tiers with No Deductible: | |||
| $204.00 | $135.0 | $31.00 | $38.00 | $69.00 | $0 | 0.0 | |||
| Gap Coverage: | No | ||||||||
| Benchmark: | not below the regional benchmark | ||||||||
| Type of Medicare Health: | Enhanced Alternative | ||||||||
| Health Plan Type: | Local PPO | ||||||||
| Similar Plan: | H5526-016 | ||||||||
| Special Needs Type: | NULL | ||||||||
| Chronic Condition: | NULL | ||||||||
| Additional Gap Coverage: | No additional gap coverage, only the Donut Hole Discount | ||||||||
| Maximum Out-of-Pocket Limit for Parts A & B (Moop): | $6,700 | ||||||||
| Annual Deductible: | NULL | ||||||||
| Annual Initial Coverage Limit ICL: | $4,130 | ||||||||
| Number of Members enrolled in this plan in Chautauqua, New York: | Plans Summary Star Rating: | Customer Service Rating: | Drug Cost Rating: | ||||||
| 295 members | 5 out of 5 Stars. This plan qualifies for the 5-star rating Special Enrollment period. Read more. | 5 out of 5 Stars. | 4 out of 5 Stars. | ||||||
| Plan Offers Mail Order: | Yes | ||||||||
| Plan Health Benefits | |||||||||
| Total # of Formulary Drugs: | 3,740 drugs | ||||||||
| Number of Members Enrolled in this Plan in Chautauqua, New York: | NULL | ||||||||
| Number of Drugs Per Tier: | NULL | ||||||||
| Preferred Pharmacy Cost Sharing During Initial Coverage Phase: | NULL | ||||||||
| Special Needs Plan SNP Eligibility Requirement: | NULL | ||||||||
| Monthly Premium Split as Follows: | |||||||||
| Part C Premium | Part D Base Premium | Part D Supplemental Premium | Total Premium | ||||||
| $135.00 | $31.00 | $38.00 | $204.00 | ||||||
| Monthly Premium with Extra Help Low Income Subsidy: | |||||||||
| LIS100 Subsidy Total Monthly Premium with LIS Parts CD | LIS25 Subsidy Monthly PartD Premium with LIS | LIS25 Subsidy Total Monthly Premium with LIS Parts CD | LIS50 Monthly PartD Premium with LIS | LIS50 Subsidy Total Monthly Premium with LIS Parts CD | LIS75 Monthly PartD Premium with LIS | LIS75 Subsidy Total Monthly Premium with LIS Parts CD | |||
| $173.00 | $61.20 | $196.20 | $53.50 | $188.50 | $45.70 | $180.70 | |||
| Formulary Drug Details: | |||||||||
| Tier 1 # of Drugs per Tier | Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) | Tier 2 # of Drugs per Tier | Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) | Tier 3 # of Drugs per Tier | Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) | Tier 4 # of Drugs per Tier | Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) | Tier 5 # of Drugs per Tier | Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase) |
| 398 | $2.00 | 1755 | $8.00 | 436 | $42.00 | 363 | $94.00 | 788 | 33% |
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