Blue Advantage, A Medicare Approved PPO

Common Questions

 

Member Specific Common Questions

What is a Medicare Advantage Plan?

A Medicare Advantage Plan is a Medicare approved program that allows you to have all the rights and protections of Original Medicare. Your Medicare benefits, however, will be provided by a private insurance company such as Blue Cross and Blue Shield of Alabama. This plan enhances your Original Medicare Benefits by adding Part D drug coverage and offering lower copayments. This plan does not require a supplemental plan. 

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Who is eligible for coverage?

To be eligible for Blue Advantage you must be a resident of Alabama. You must also be entitled to and enrolled in Medicare Parts A & B. To be eligible for Medicare you must be 65 years of age or on disability. Our contract with CMS is renewed annually and the availability of coverage beyond the current contract year is not guaranteed.

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What if I have more than one address?

If you have more than one address, you will need to provide your permanent physical address on your application. This address must match your primary address as listed with Social Security and Medicare. Your address will be used to determine your product eligibility and plan premiums. Failure to report your correct address can delay the processing of your application or result in the loss of coverage. If necessary, you may also provide an alternate address (such as a Post Office Box) where you prefer to receive mailings. 

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How much does Blue Advantage cost?

Premium rates for Blue Advantage plans are based on the benefit design and overall utilization of medical services for each county. You can view available plans and rates for your area here.

With all options, you are required to continue paying your Medicare Part B premium unless otherwise paid for by Medicaid or another third party. If you qualify for Low Income Subsidy, your premium may be reduced based on the level of subsidy for which you qualify.

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What additional benefits are offered if I elect the Blue Advantage Premier Plan at a higher premium?

  • Lower copays for inpatient and outpatient hospital services
  • Lower copays for doctor's office visits (both primary care and specialists)
  • No deductible for prescription drugs

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Why are the premiums different in some areas of the state compared to others?

Premium rates for Blue Advantage plans are based on the benefit design and overall utilization of medical services for each county. Blue Cross' objective continues to be to provide customers with access to the highest quality healthcare in the most cost-effective manner.

Each year, Medicare Advantage and Part D plans renew their contracts with Medicare. Changes can be made to premiums, benefits, deductibles, copayments, coinsurance, formularies and other services once annually. Any other changes throughout the year must be approved by Medicare. It is VERY important to review your plan every year to determine whether it will continue to meet your needs for the upcoming year.

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What are my payment options?

Premiums are always due on the 1st of the month and are considered late if not received by the 10th.

There are several ways you can pay your plan premium:

  • Automatic monthly payment by E-Check, Credit Card, or Debit Card
  • Online at www.bcbsalmedicare.com after registering for myBlueCross
  • Over the telephone with Visa, MasterCard, Discover or E-Check
  • Automatic deduction from your monthly Social Security or Railroad Retirement Board benefits check
  • Mail a check
  • Set up online bill payment through your financial institution. Please be sure to include your contract number when setting up online bill payment.

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How do I set up automatic monthly payments?

Call Member Services to set up by telephone. All payments are drafted on the first business day of each month.

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When is the Annual Election Period (AEP)?

The Annual Election Period allows you to make changes to your plan anytime between October 15 and December 7. Elections made during this time will be effective on January 1 of the following year. When Medicare has been notified of your election change, your membership with your previous MAPD and/or Part D plan will be cancelled effective December 31. To cancel coverage other than Medicare Advantage or Part D Plans, please contact your insurance carrier. 

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Can I make changes outside of the Annual Election Period (AEP)?

A new enrollee is allowed to make a one-time change during the Medicare Advantage Disenrollment Period (MADP), which takes place from January 1 to February 14. This period allows you to disenroll from a Medicare Advantage plan and return to your Original Medicare. You are not allowed to change from one Medicare Advantage plan to another Medicare Advantage plan or from one Part D plan to another Part D Plan.

Other times that you are allowed to make changes to your coverage outside of AEP are:

  • Initial Coverage Election Period (ICEP) - three months before your Medicare eligibility effective date, the month of your Medicare eligibility date, and three months after.
  • Special Election Period (SEP) - You can change plans anytime during the year if you qualify for Low Income Subsidy. You are also allowed to make elections within 60 days of the day you lose coverage with your employer and within 60 days of the day you move into a new coverage area.

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How do I enroll in Blue Advantage?

There are several ways to submit your enrollment application:

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If I enroll in a new plan, when will my prior coverage end?

Your membership will end the last day of the month prior to when your new plan's coverage begins.

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How do I know if a provider is in the Blue Advantage network?

Blue Advantage offers a large network of providers who are willing to serve you.

To see if an Alabama provider participates in the Blue Advantage network, you may:

  • Visit our online doctor finder
  • Call the Member Services number on the back of your ID card (non-members may call 1-888-543-9212)
  • Request that a Provider Directory for your county be mailed to you

Outside of Alabama, medical emergencies and visits to an Urgent Care Facility will process at an in-network benefit level, regardless of whether the provider is in the Blue Advantage network. For all other services outside of the coverage area, facility and provider participation may vary. To find out if an out-of-state facility or provider participates in the Blue Advantage network, contact Member Services.

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What type of discounts will I receive during the coverage gap or donut hole?

Once the amount of drugs you have purchased for the year reaches $3,700 you will enter the coverage gap. Blue Advantage does not provide any coverage during the gap. However, you will receive a 60% discount on brand drugs if the manufacturer is contracted with CMS. For generic drugs, you will be discounted up to 49% of the plan allowable cost. After your total out-of-pocket cost reaches $4,950 you will enter the Catastrophic Coverage Phase. During this final phase, you will pay the greater of 5% coinsurance or a $3.30 copay for generic drugs/$8.25 copay for brand drugs. If you need additional assistance during the coverage gap, please contact your pharmacy for manufacturer discount programs, or call Social Security at 1-800-772-1213 to see if you qualify for extra help with your prescription drugs.

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Do you offer gym/fitness memberships or discounts?

Blue Advantage membership includes SilverSneakers®, a fun, energizing program that helps older adults take greater control of their health by encouraging physical activity and offering social events. SilverSneakers benefits include:

  • Basic fitness membership at any participating location
  • Signature SilverSneakers group exercise classes designed exclusively for older adults
  • Support from trained Senior Advisors
  • Health education and social activities
  • Exclusive member Web portal with exercise and nutrition plans, recipes, health resources, and much more

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Do you have a nurse that I can speak with regarding my health?

Yes; we offer a 24-hour Nurse Line to our members. This line is available 24 hours, 7 days a week for members who have general questions concerning their health. You can reach the Nurse Line at 1-800-896-2724. Although this service is available, please remember to always consult your doctor or pharmacist concerning any new services or upon taking any new medications.

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What additional health programs or services are available?

Blue Cross has several programs in place, such as our health management and disease management programs, to help reduce the cost of health care. Blue Cross nurses actively work with members to provide support for chronic conditions, such as diabetes and heart disease, so our members can improve their overall health and wellness. In addition, wellness programs like SilverSneakers®, myBlueWellness and WalkingWorks® are available to all of our members, and they are free services.

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What are star ratings?

CMS created the Five-Star Quality Rating System to help consumers compare plans more easily. They rate plan performances in different areas such as: customer service, member satisfaction, drug pricing, patient safety, etc. CMS requires Medicare Advantage and Part D Plans to include their star ratings in pre-enrollment packets. Medicare monitors all healthcare and prescription drug plans. The number of stars a plan receives gives you an overall rating for the plan as a whole, and Medicare hopes this rating will help you choose a plan that is right for you. View our plan star rating.

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What impact does Health Care Reform have for my plan?

Beginning in 2012, no deductibles or copayments are required for many preventive services received in-network. Examples include an annual wellness visit, colon cancer screening (colorectal), flu shots, glaucoma screenings, mammograms and prostate cancer screenings. A complete list of preventive services is available in the Summary of Benefits : Complete Summary Premier Summary.

Additionally, national Health Care Reform provisions gradually reduce the coverage gap, or "donut hole," for prescription drug coverage. 

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How can I talk with a Blue Cross representative for more information?

  • Call us at 1-888-543-9212 (TTY 711) from 8 a.m. to 8 p.m., 7 days a week
  • Sign up to attend a meeting  with a local representative

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Can I keep my coverage if I move?

This plan is only available to Alabama residents. Please note that failure to report an address change can result in the loss of your coverage.

If you move within the state of Alabama, you are still eligible to keep your Blue Advantage plan; however, premium and plan options may vary based on the county that you live in. Please contact our Member Services Department to advise of an address change and to determine if your move will constitute any changes to your plan.

If you move outside of Alabama, Medicare will allow you 60 days from the day you move to enroll into another MAPD or Part D plan that is located in your new state.  If you are temporarily moving out of the coverage area, you are allowed to have a temporary address for up to 6 months. You are responsible for notifying us if your living status changes from a temporary to permanent residence or of any permanent changes to your physical address.

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Member Specific Common Questions

 

Why am I receiving my Annual Notice of Change (ANOC) packet so soon?

Medicare requires all Medicare Advantage and Prescription Drug plans to notify members of the upcoming year's changes by September 30 of each calendar year. 

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Will I receive a new ID card annually?

ID cards do not expire and will not be issued annually. If you need a new ID card, please contact Member Services at 1-888-234-8266.

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If I qualify for Low Income Subsidy (LIS) this year, will I qualify again next year?

Please contact the Social Security Administration to see if you are required to reapply for Low Income Subsidy each year. There is no guarantee that you will automatically qualify each year, as the income criteria is subject to change. The Social Security Administration can be reached at 1-800-772-1213. If eligible for LIS, Social Security will send you a letter advising of your level of eligibility. Blue Cross and Blue Shield of Alabama will also be notified of any changes to your LIS eligibility.

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What is Best Available Evidence (BAE)?

Learn more about BAE and how to provide it.

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Why do I have to pay an extra Part D amount because of my income? (Part D Income Related Monthly Adjustment Amount- IRMAA)

If your modified adjusted gross income, as reported on your IRS tax return, is above a certain amount ($85,000 for individual, $170,000 for married couples), you will pay an extra amount in addition to your monthly plan premium. You may also hear this referred to as a surcharge, and can get more information on it here.If you have to pay an extra amount, the Social Security Administration (SSA) will send you a letter to advise what the extra amount is and how to pay it.

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What if I decide to change the way I pay my premium?

Depending on the payment method selected, it can take up to three months for your new payment method to take effect. In the meantime, you are responsible for making sure your plan premium is paid on time.

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How do I know if my prescription drugs are covered?

To see if a specific drug is covered under Blue Advantage you may:

  • View formularies online: Complete and Premier
  • Look up your drug in our Find Drugs tool
  • Call the Member Services number on the back of your ID card (non-members may call 1-888-543-9212)
  • Request that a formulary be mailed to you

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My drug is not on your formulary. How can I get it added?

To request coverage for a medication not on the formulary, contact your physician and ask that a formulary exception request form be submitted on your behalf. This process can take up to 72 hours for a standard request. If your life, health or ability to regain maximum function may be at risk by waiting for a standard request decision, we will let you know our decision within 24 hours. This is considered an expedited request. If a non-formulary medication is approved to be added to your formulary, the copay will process as a Tier 4 for brand name drugs or Tier 2 for generic drugs.

You may also contact Member Services at 1-888-234-8266, 8 a.m. to 8 p.m., seven (7) days a week. From February 15 to September 30, on weekends and holidays you may be required to leave a message. Calls will be returned the next business day. 

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How do I file a paper claim for prescription drugs?

Send your request for payment, along with receipts documenting the amount paid, to:


Part D Claims
PO Box 20970
Lehigh Valley, PA 18002-0970

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Can I fill my prescriptions by mail?

Yes, we offer the convenience of having your medications purchased through our mail order programs with Prime Mail and Walgreens. The benefits of using mail order include:

  • Saves Money by getting a 90-day supply for only 2 copays with free shipping
  • Saves Time since it's delivered to your home and no refills are needed for several months
  • Offers Convenience: You can order refills online, by mail or by phone

There are several ways to enroll in mail order. To register for these services please call or visit the websites below:

PrimeMail
PrimeMail Website
1-800-731-3588
TTY: 711, 24 hours a day, 7 days a week

Walgreens
Walgreens Website
1-800-489-2197
TTY: 1-800-573-1833, 24 hours a day, 7 days a week

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What are your Quality Assurance policies and procedures?

Blue Cross and Blue Shield of Alabama offers a number of standard Drug Utilization Management (DUM) services such as formulary management, prior authorization, quantity limits and step-therapy. These programs encourage safe, appropriate and cost-effective use of drugs. The goal of DUM is to monitor and prevent over- and under-utilization of prescription drugs while respecting the physician's prescribing authority. Using DUM, we also track and trend utilization, identify opportunities for improvement, and document and implement corrective actions when necessary. All policies are reviewed quarterly by an independent committee of pharmacists and physicians.

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What is the Medication Therapy Management (MTM) Program?

The MTM Program is a free service offered by your plan that can help you keep your medications on the right track. To learn more about the MTM Program go here.

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What is Prime Therapeutics LLC?

Prime Therapeutics is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Alabama Blue Advantage (PPO) members.

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Notices