2024 Blue Shield Retiree PPO - Group ID: W0051428, Plan ID: PPOX0005
Basics
Lifetime maximum
No maximum
Plan Year
2024
Offered To
Medicare Retirees
Body/Description
This plan provides coverage from any licensed physician anywhere in the world, and pays Medicare Part A and Part B deductibles and co-insurance for all Medicare-approved services. This plan covers some services not covered by Medicare.
You will have lower costs if you use a provider who accepts Medicare assignment and is a Blue Shield PPO network provider.
As a Medicare Supplement plan, this plan coordinates with Medicare. Many of the expenses that are covered by Medicare are paid at 100% of the Medicare Allowable Amount. Many of the non-Medicare approved services are first subject to the deductible and are covered at 80%.
Coinsurance
100% for Medicare Approved services; 100% for Preventive Services; 80% after deductible for Non-Medicare Approved or other services
Office co-pay
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Deductible
Medicare-Approved: Deductibles Waived
Non-Medicare Approved: $100 per individual/$300 family
Non-Medicare Approved: $100 per individual/$300 family
Benefit Type
Medical
Annual maximum
Medicare-Approved or Non-Medicare Approved: $1,000 per individual
X-rays
Medicare-Approved:
100% Non-Medicare Approved: 80% after deductible
100% Non-Medicare Approved: 80% after deductible
Maternity Hospital Stay
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Baby's First Exam
Not covered
Birthing Centers
Medicare Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Midwives
Medicare Approved: Not covered
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Prenatal Visits
Medicare Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Doctor Delivery Charge
Covered the same as all other inpatient surgery
Reproductive Health
Medicare Approved: 100% Non-Medicare Approved: 80% after deductible
Mental Health
INPATIENT CARE
Pre-Certification is required by you or your provider.
Medicare Approved: 100%
Non-Medicare Approved: 60% after deductible
OUTPATIENT CARE
[no visit limit]
Medicare Approved: 100%
Non-Medicare Approved: 80% after deductible
Pre-Certification is required by you or your provider.
Medicare Approved: 100%
Non-Medicare Approved: 60% after deductible
OUTPATIENT CARE
[no visit limit]
Medicare Approved: 100%
Non-Medicare Approved: 80% after deductible
Autism
NA
Substance Abuse
INPATIENT DETOXIFICATION
Pre-Certification is required by you or your provider.
Medicare Approved: 100%
Non-Medicare Approved: 60% after deductible
OUTPATIENT CARE
[no visit limit]
Medicare Approved: 100%
Non-Medicare Approved: 80% after deductible
Pre-Certification is required by you or your provider.
Medicare Approved: 100%
Non-Medicare Approved: 60% after deductible
OUTPATIENT CARE
[no visit limit]
Medicare Approved: 100%
Non-Medicare Approved: 80% after deductible
Acupuncture
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Up to 20 visits per year Medicare-Approved and Non-Medicare Approved combined.
Non-Medicare Approved: 80% after deductible
Up to 20 visits per year Medicare-Approved and Non-Medicare Approved combined.
Allergy Tests
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Allergy Treatment
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Alternative Medicine
Not covered
Ambulance charges
Medicare-Approved: 100% after $50 co-pay
Non-Medicare Approved: 80% of the allowed amount after $50 co-pay
Non-Medicare Approved: 80% of the allowed amount after $50 co-pay
CT Scans
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Chiropractors
Up to $1,500 max benefit per calendar year
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Christian Science Practitioners
Not covered
Cosmetic Surgery
Not covered
Dental Treatment
Coverage limited to certain conditions only. Contact Blue Shield for more information.
Emergency Room
Including emergency room professional and lab/ancillary charges
Medicare-Approved: 100% after $100 facility co-pay per visit (co-pay waived if admitted)
Non-Medicare Approved: 80% after $100 facility co-pay per visit (co-pay waived if admitted)
Medicare-Approved: 100% after $100 facility co-pay per visit (co-pay waived if admitted)
Non-Medicare Approved: 80% after $100 facility co-pay per visit (co-pay waived if admitted)
Urgent Care
Medicare-Approved: 100%; Non-Medicare Approved: 80% after deductible
Hearing Care
Medicare-Approved: 100% for annual exams
Non-Medicare Approved: 100% for annual exams
Hearing aids not covered
Non-Medicare Approved: 100% for annual exams
Hearing aids not covered
Home Health Care
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Hospice Care
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Hospital Stay
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Infertility Treatment
Not covered.
Laboratory Charges
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Magnetic resonance imaging - MRI
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Durable Medical Equipment
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Occupational Therapy
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Organ Transplants
Contact Blue Shield for information on transplant coverage benefits
Skilled Nursing
Medicare-Approved: 100% up to 120 calendar days/year Non-Medicare Approved: 80% after deductible up to 120 calendar days/year
Physical Therapy
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Surgery : Physician Services
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Surgery : Facility Charges
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
Speech Therapy
NA
Tubal Ligation
NA
Vasectomy
Medicare-Approved: 100%
Non-Medicare Approved: 80% after deductible
Non-Medicare Approved: 80% after deductible
X-rays
Medicare-Approved:
100% Non-Medicare Approved: 80% after deductible
100% Non-Medicare Approved: 80% after deductible
Pharmacy (Retail)
90-day supply of maintenance drugs available at Retail Pharmacy, subject to 3 co-pays.
Blue Shield Network pharmacy: $10 generic; $30 brand name; $75 non-formulary -- up to a 30-day supply.
Non-Network Pharmacy: 25% + $10 for Generic: 25% + $30 for brand name: 25% + $75 for non-formulary
Blue Shield Network pharmacy: $10 generic; $30 brand name; $75 non-formulary -- up to a 30-day supply.
Non-Network Pharmacy: 25% + $10 for Generic: 25% + $30 for brand name: 25% + $75 for non-formulary
Mail order drug program
Must use Blue Shield Mail Order Service. $20 generic; $60 brand name; $150 non-formulary -- up to a 90-day supply
Birth Control Pills
Included in Prescription Drug benefit
Physical exams for adults
100%
Annual exam
Annual exam
Physical exams for children
Not covered
Pap smears
Medicare-Approved: 100%
Non-Medicare Approved: 100%
Non-Medicare Approved: 100%
Mammograms
Medicare-Approved: 100%
Non-Medicare Approved: 100%
Non-Medicare Approved: 100%
Immunizations
Medicare-Approved: 100%
Non-Medicare Approved: 100%
Travel immunizations - No charge for both Medicare approved and non-Medicare approved
Non-Medicare Approved: 100%
Travel immunizations - No charge for both Medicare approved and non-Medicare approved
Prostate Specific Antigen test - PSA
Medicare-Approved: 100%
Non-Medicare Approved: 100%
Non-Medicare Approved: 100%
Well-woman visits
Medicare-Approved: 100%
Non-Medicare Approved: 100%
Non-Medicare Approved: 100%
Vision care
100% no deductible
Limited to screen and refraction exams only; eyewear not covered
Limited to screen and refraction exams only; eyewear not covered
Transgender Services
"Gender affirming care includes: Hysterectomy and salpingo-oophrectomy (female-to-male) and orchiectomy (maleto-female)
Mastectomy, subcutaneous mastectomy, breast reduction (creation of a male chest), including nipple tattooing, (female-to-male).Any combination of the following genital reconstructive surgeries (as applicable to gender affirmation): Vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, urethromeatoplasty, implantation of a testicular prosthesis, and phalloplasty (employing a pedicled or free vascularized flap) (female-to-male); or Vaginoplasty, penectomy, clitoroplasty, vulvuloplasty (including colovaginoplasty, labiaplasty, penile skin inversion, repair of introitus, construction of vagina with graft, coloproctostomy) (male-to-female)"
Mastectomy, subcutaneous mastectomy, breast reduction (creation of a male chest), including nipple tattooing, (female-to-male).Any combination of the following genital reconstructive surgeries (as applicable to gender affirmation): Vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, urethromeatoplasty, implantation of a testicular prosthesis, and phalloplasty (employing a pedicled or free vascularized flap) (female-to-male); or Vaginoplasty, penectomy, clitoroplasty, vulvuloplasty (including colovaginoplasty, labiaplasty, penile skin inversion, repair of introitus, construction of vagina with graft, coloproctostomy) (male-to-female)"
Travel and Lodging
Contact the plan for details
Benefit Perks
Fitness Your Way monthly membership can be purchased for $25/month plus a one-time enrollment fee of $25, which provides access to participating network fitness locations.