5

5 out of 5 stars* for plan year 2024

Plan ID: H5526-018

What You Need to Know:

  • BlueShield Forever Blue 770 (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 $200, 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).
  • BlueShield Forever Blue 770 (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 $42.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$200

Monthly Premium

Medicare Plan Features
Monthly Premium: $200.00
Part C Premium: $126.7
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$200.00 $126.7 $41.70 $31.60 $73.30 $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: H5526-020
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 Albany, New York: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
180 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 Albany, 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
$126.70 $41.70 $31.60 $200.00
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
$158.30 $62.90 $189.60 $52.40 $179.10 $42.00 $168.70
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 $12.00 436 $42.00 363 $94.00 788 33%

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MVP Medicare Patriot Plan with Part D (PPO) (2023)Local PPO$7,550$250
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UnitedHealthcare Medicare Advantage Choice Plan 4 (Region (2023)Regional PPO$6,700$150
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HumanaChoice H5970-015 (PPO) (2023)Local PPO$6,500$250
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Aetna Medicare Premier Plan (PPO) (2023)Local PPO$7,550$200
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BlueShield Freedom Nation (PPO) (2023)Local PPO$7,550$375
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Humana Gold Plus H3533-013 (HMO) (2023)Local HMO$6,700$275
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HumanaChoice H5970-018 (PPO) (2023)Local PPO$7,550$310
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BlueShield Freedom Plus (HMO) (2023)Local HMO$6,700$275
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Aetna Medicare Elite Plan (PPO) (2023)Local PPO$7,550$100
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WellCare Patriot (HMO) (2023)Local HMO *$6,700$-
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BlueShield Freedom Premier (HMO) (2023)Local HMO$6,700$100
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HumanaChoice H5970-019 (PPO) (2023)Local PPO$5,500$0
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BlueShield Freedom No Rx (HMO) (2023)Local HMO *$6,700$-
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CDPHP Choice (HMO) (2023)Local HMO *$5,000$-
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WellCare Value (HMO) (2023)Local HMO$6,700$0
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CDPHP Choice Rx (HMO) (2023)Local HMO$5,000$0
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Fidelis Medicare Advantage Flex (HMO-POS) (2023)Local HMO$7,550$445
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Aetna Medicare Credit Plan (PPO) (2023)Local PPO$7,550$250
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EmblemHealth VIP Rx Saver (HMO) (2023)Local HMO$7,550$395
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Fidelis Medicare $0 Premium (HMO) (2023)Local HMO$7,550$0
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EmblemHealth VIP Part B Saver (HMO) (2023)Local HMO$7,550$445
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CDPHP Basic RX (HMO) (2023)Local HMO$6,700$0
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Aetna Medicare Eagle Plan (PPO) (2023)Local PPO *$7,550$-
5
CDPHP Flex (PPO) (2023)Local PPO *$5,500$-
5
MVP SmartFund (MSA) (2023)MSA *$-$-
4
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4
EmblemHealth VIP Go (HMO-POS) (2023)Local HMO$7,550$250
2
WellCare Today's Options Premier 300 (PFFS) (2023)PFFS *$-$-
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CDPHP $0 Medicare Rx (HMO) (2023)Local HMO$7,500$300
5
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Humana Gold Plus H3533-006 (HMO) (2023)Local HMO$7,200$300
4
MVP Medicare Preferred Gold without Part D (HMO-POS) (2023)Local HMO *$7,550$-
4
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5
BlueShield Senior Blue 652 (HMO) (2023)Local HMO$6,700$0
3
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5
WellCare Today's Options Premier Plus 250A (PFFS) (2023)PFFS$-$0
5
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5
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WellCare Today's Options Premier Plus 650B (PFFS) (2023)PFFS$-$0
5
MVP Medicare Preferred Gold with Part D (HMO-POS) (2023)Local HMO$5,800$0
4
MVP Medicare Secure Plus with Part D (HMO-POS) (2023)Local HMO$7,550$0
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BlueShield Freedom No Rx (HMO) (2023)Local HMO *$6,700$-
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