- 2021 Lis Reference Sheet
- Lis Copays For 2021
- Lis Levels For 2021
The 2021 FPL guidelines will be used for determining LIS qualifications during the 2021 plan year and at the beginning of the 2022 plan year. If your income is below 135% of the FPL ($17,388 if you are single or $23,517 for married couples), you could qualify for the full Low-Income Subsidy (resource limits also apply - see chart above). This is the most you pay for copays, coinsurance, and other costs for medical services for the year. Inpatient Hospital Coverage In-Network: $285 copay per day for days 1 through 6 per stay You pay nothing per day for days 7 and beyond per stay Out-of-Network: $450 copay per day for days 1 through 6 per stay You pay nothing per day.
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BlueJourney Prime (PPO) H3923-017 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Capital Advantage Insurance Company available to residents in Pennsylvania. This plan includes additional Medicare prescription drug (Part-D) coverage. The BlueJourney Prime (PPO) has a monthly premium of $171.00 and has an in-network Maximum Out-of-Pocket limit of $4,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,000 out of pocket. This can be a extremely nice safety net.
BlueJourney Prime (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of 'preferred' providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.
Capital Advantage Insurance Company works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for BlueJourney Prime (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Capital Advantage Insurance Company and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Capital Advantage Insurance Company except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
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2021 Capital Advantage Insurance Company Medicare Advantage Plan Costs
| Name: |
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| Plan ID: | H3923-017 |
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| Provider: | Capital Advantage Insurance Company |
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| Year: | 2021 |
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| Type: | Local PPO |
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| Monthly Premium C+D: | $171.00 |
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| Part C Premium: | $147.4 |
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| MOOP: | $4,000 |
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| Part D (Drug) Premium: | $23.60 |
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| Part D Supplemental Premium | $0 |
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| Total Part D Premium: | $23.60 |
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| Drug Deductible: | $0 |
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| Tiers with No Deductible: | 0 |
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| Gap Coverage: | No |
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| Benchmark: | not below the regional benchmark |
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| Type of Medicare Health: | Enhanced Alternative |
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| Drug Benefit Type: | Enhanced |
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| Similar Plan: | H3923-028 |
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BlueJourney Prime (PPO) Part-C Premium
Capital Advantage Insurance Company plan charges a $147.4 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
H3923-017 Part-D Deductible and Premium
BlueJourney Prime (PPO) has a monthly drug premium of $23.60 and a $0 drug deductible. This Capital Advantage Insurance Company plan offers a $23.60 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0 this Premium covers any enhanced plan benefits offered by Capital Advantage Insurance Company above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $23.60. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
2021 Lis Reference Sheet
Capital Advantage Insurance Company Gap Coverage
In 2021 once you and your plan provider have spent $4130 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Capital Advantage Insurance Company plan does not offer additional coverage through the gap.
Premium Assistance
The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The BlueJourney Prime (PPO) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $5.90 for 75% low income subsidy $11.80 for 50% and $17.70 for 25%.
| Full LIS Premium: | $0 |
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| 75% LIS Premium: | $5.90 |
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| 50% LIS Premium: | $11.80 |
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| 25% LIS Premium: | $17.70 |
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H3923-017 Formulary or Drug Coverage
BlueJourney Prime (PPO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
2021 BlueJourney Prime (PPO) Summary of Benefits
Additional Benefits
Comprehensive Dental
| Diagnostic services | Not covered |
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| Endodontics | 50% coinsurance (Out-of-Network) |
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| Endodontics | 50% coinsurance |
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| Extractions | 50% coinsurance (Out-of-Network) |
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| Extractions | 50% coinsurance |
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| Non-routine services | 50% coinsurance |
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| Non-routine services | 50% coinsurance (Out-of-Network) |
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| Periodontics | Not covered |
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| Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (Out-of-Network) |
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| Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance |
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| Restorative services | 50% coinsurance (Out-of-Network) |
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| Restorative services | 50% coinsurance |
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Deductible
Diagnostic Tests and Procedures
| Diagnostic radiology services (e.g., MRI) | $125 copay |
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| Diagnostic radiology services (e.g., MRI) | $125 copay (Out-of-Network) |
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| Diagnostic tests and procedures | $10 copay (Out-of-Network) |
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| Diagnostic tests and procedures | $10 copay |
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| Lab services | $10 copay |
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| Lab services | $10 copay (Out-of-Network) |
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| Outpatient x-rays | $20 copay |
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| Outpatient x-rays | $20 copay (Out-of-Network) |
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Doctor Visits
| Primary | $5 copay per visit |
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| Primary | $5 copay per visit (Out-of-Network) |
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| Specialist | $25 copay per visit (Out-of-Network) |
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| Specialist | $25 copay per visit |
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Emergency care/Urgent Care
| Emergency | $90 copay per visit (always covered) |
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| Urgent care | $35 copay per visit (always covered) |
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Foot Care (podiatry services)
| Foot exams and treatment | $25 copay (Out-of-Network) |
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| Foot exams and treatment | $25 copay |
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| Routine foot care | Not covered |
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Ground Ambulance
| $150 copay |
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| $150 copay (Out-of-Network) |
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Hearing
| Fitting/evaluation | 50% coinsurance (Out-of-Network) |
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| Fitting/evaluation | $0 copay |
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| Hearing aids | $0 copay (Out-of-Network) |
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| Hearing aids | $0 copay |
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| Hearing exam | $25 copay |
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| Hearing exam | $25 copay (Out-of-Network) |
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Inpatient Hospital Coverage
$100 per day for days 1 through 6
$0 per day for days 7 through 90 (Out-of-Network) |
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$100 per day for days 1 through 6
$0 per day for days 7 through 90 |
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Medical Equipment/Supplies
| Diabetes supplies | $0 copay per item |
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| Diabetes supplies | 20% coinsurance per item (Out-of-Network) |
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| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item |
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| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Out-of-Network) |
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| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Out-of-Network) |
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| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item |
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Lis Copays For 2021
Medicare Part B Drugs
| Chemotherapy | 20% coinsurance (Out-of-Network) |
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| Chemotherapy | 20% coinsurance |
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| Other Part B drugs | 20% coinsurance (Out-of-Network) |
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| Other Part B drugs | 20% coinsurance |
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Mental Health Services
| Inpatient hospital - psychiatric | $100 per day for days 1 through 6
$0 per day for days 7 through 90 (Out-of-Network) |
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| Inpatient hospital - psychiatric | $100 per day for days 1 through 6
$0 per day for days 7 through 90 |
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| Outpatient group therapy visit | $30 copay |
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| Outpatient group therapy visit | $30 copay (Out-of-Network) |
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| Outpatient group therapy visit with a psychiatrist | $30 copay |
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| Outpatient group therapy visit with a psychiatrist | $30 copay (Out-of-Network) |
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| Outpatient individual therapy visit | $30 copay (Out-of-Network) |
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| Outpatient individual therapy visit | $30 copay |
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| Outpatient individual therapy visit with a psychiatrist | $30 copay (Out-of-Network) |
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| Outpatient individual therapy visit with a psychiatrist | $30 copay |
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MOOP
$6,000 In and Out-of-network
$4,000 In-network |
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Option
Optional supplemental benefits
Outpatient Hospital Coverage
| $225 copay per visit (Out-of-Network) |
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| $225 copay per visit |
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Preventive Care
| $0 copay |
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| 20% coinsurance (Out-of-Network) |
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Preventive Dental
| Cleaning | Covered under office visit |
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| Dental x-ray(s) | Covered under office visit |
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| Fluoride treatment | Not covered |
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| Office visit | 50% coinsurance (Out-of-Network) |
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| Office visit | $10.00 |
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| Oral exam | Covered under office visit |
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Rehabilitation Services
| Occupational therapy visit | $25 copay |
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| Occupational therapy visit | $25 copay (Out-of-Network) |
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| Physical therapy and speech and language therapy visit | $25 copay |
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| Physical therapy and speech and language therapy visit | $25 copay (Out-of-Network) |
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Skilled Nursing Facility
$0 per day for days 1 through 20
$160 per day for days 21 through 100 (Out-of-Network) |
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$0 per day for days 1 through 20
$160 per day for days 21 through 100 |
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Transportation
| 50% coinsurance (Out-of-Network) |
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| $0 copay |
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Vision
| Contact lenses | $0 copay |
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| Contact lenses | $0 copay (Out-of-Network) |
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| Eyeglass frames | $0 copay |
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| Eyeglass frames | $0 copay (Out-of-Network) |
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| Eyeglass lenses | $0 copay (Out-of-Network) |
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| Eyeglass lenses | $0 copay |
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| Eyeglasses (frames and lenses) | Not covered |
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| Other | Not covered |
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| Routine eye exam | $20 copay |
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| Routine eye exam | 50% coinsurance (Out-of-Network) |
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| Upgrades | Not covered |
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Wellness Programs (e.g. fitness nursing hotline)
Reviews for BlueJourney Prime (PPO) H3923
| 2019 Overall Rating |
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| Part C Summary Rating |
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| Part D Summary Rating |
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| Staying Healthy: Screenings, Tests, Vaccines |
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| Managing Chronic (Long Term) Conditions |
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| Member Experience with Health Plan |
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| Complaints and Changes in Plans Performance |
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| Health Plan Customer Service |
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| Drug Plan Customer Service |
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| Complaints and Changes in the Drug Plan |
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| Member Experience with the Drug Plan |
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| Drug Safety and Accuracy of Drug Pricing |
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Staying Healthy, Screening, Testing, & Vaccines
| Total Preventative Rating |
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| Breast Cancer Screening |
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| Colorectal Cancer Screening |
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| Annual Flu Vaccine |
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| Improving Physical |
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| Improving Mental Health |
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| Monitoring Physical Activity |
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| Adult BMI Assessment |
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Managing Chronic And Long Term Care for Older Adults
| Total Rating |
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| SNP Care Management |
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| Medication Review |
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| Functional Status Assessment |
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| Pain Screening |
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| Osteoporosis Management |
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| Diabetes Care - Eye Exam |
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| Diabetes Care - Kidney Disease |
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| Diabetes Care - Blood Sugar |
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| Rheumatoid Arthritis |
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| Reducing Risk of Falling |
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| Improving Bladder Control |
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| Medication Reconciliation |
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| Statin Therapy |
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Member Experience with Health Plan
| Total Experience Rating |
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| Getting Needed Care |
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| Customer Service |
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| Health Care Quality |
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| Rating of Health Plan |
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| Care Coordination |
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Member Complaints and Changes in BlueJourney Prime (PPO) Plans Performance
| Total Rating |
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| Complaints about Health Plan |
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| Members Leaving the Plan |
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| Health Plan Quality Improvement |
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| Timely Decisions About Appeals |
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Health Plan Customer Service Rating for BlueJourney Prime (PPO)
| Total Customer Service Rating |
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| Reviewing Appeals Decisions |
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| Call Center, TTY, Foreign Language |
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BlueJourney Prime (PPO) Drug Plan Customer Service Ratings
| Total Rating |
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| Call Center, TTY, Foreign Language |
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| Appeals Auto |
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| Appeals Upheld |
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Lis Levels For 2021
Ratings For Member Complaints and Changes in the Drug Plans Performance
| Total Rating |
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| Complaints about the Drug Plan |
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| Members Choosing to Leave the Plan |
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| Drug Plan Quality Improvement |
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Member Experience with the Drug Plan
| Total Rating |
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| Rating of Drug Plan |
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| Getting Needed Prescription Drugs |
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Drug Safety and Accuracy of Drug Pricing
| Total Rating |
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| MPF Price Accuracy |
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| Drug Adherence for Diabetes Medications |
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| Drug Adherence for Hypertension (RAS antagonists) |
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| Drug Adherence for Cholesterol (Statins) |
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| MTM Program Completion Rate for CMR |
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| Statin with Diabetes |
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Ready to Enroll?
Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST
Coverage Area for BlueJourney Prime (PPO)
(Click county to compare all available Advantage plans)
| State: | Pennsylvania
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| County: | Adams,Berks,Centre,Columbia,Cumberland,
Dauphin,Franklin,Fulton,Juniata,
Lancaster,Lebanon,Lehigh,Mifflin,
Montour,Northampton,Northumberland,Perry,
Schuylkill,Snyder,Union,York,
|
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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.Includes 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.