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Important Legal Information and Disclaimers

Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx (PDP) Members

My Benefits

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Blue Medicare HMO and Blue Medicare PPO

Monthly Plan Premium for People who get Extra Help from Medicare to
Help Pay for their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get extra help.

2014 LIS Table
Your level of extra help Monthly Premium for Blue Medicare
HMO Standard*
Monthly Premium for Blue Medicare
HMO Enhanced*
Monthly Premium for Blue Medicare
PPO Enhanced*
Monthly Premium for Blue Medicare
PPO Enhanced Freedom*
100% $0.00 $1.00 $16.50 $93.00
75% $0.00 $5.50 $21.90 $100.10
50% $0.00 $9.90 $27.20 $107.20
25% $0.00 $14.40 $32.60 $114.20
2015 LIS Table
Your level of extra help Monthly Premium for Blue Medicare
HMO Essential*
Monthly Premium for Blue Medicare
HMO Standard*
Monthly Premium for Blue Medicare
HMO Enhanced*
Monthly Premium for Blue Medicare
PPO Enhanced*
Monthly Premium for Blue Medicare
PPO Enhanced Freedom*
100% $34.20 $11.90 $35.10 $28.10 $112.70
75% $41.50 $18.50 $42.40 $35.40 $120.00
50% $48.80 $25.10 $49.70 $42.70 $127.30
25% $56.20 $31.80 $57.10 $50.10 $134.70

*This does not include any Medicare Part B premium you may have to pay.

Blue Medicare HMO's and Blue Medicare PPO's premium includes coverage for both medical services and prescription drug coverage.

If you aren't getting extra help, you can see if you qualify by calling:

  • Your State Medicaid Office, or
  • The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please call Customer Services at 1-888-310-4110, (TTY/TDD: 1-888-451-9957) from 8 a.m. to 8 p.m., 7 days a week.

In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.

To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.

Please click on the link to CMS website below for materials related to the CMS Best Available Evidence (BAE) policy.
http://www.cms.hhs.gov/prescriptiondrugcovcontra/17_best_available_evidence_policy.asp



Important Legal Information and Disclaimers

The information on this page is current as of 10/1/2014.

Y0079_6741 CMS Approved 10022014