What you should know about Blue Cross^® Medicare Private Fee for Service and Medicare Plus Blue^SM PPO

Plan information

Blue Cross Medicare Private Fee for Service

Medicare Plus Blue PPO

Contractual agreement

The contractual agreement language is the same for both, but health care providers sign separate contracts.

Provider network

Networks are separate. Providers can choose to participate in one or both. We encourage providers, including hospitals and skilled nursing care facilities, to participate in both networks to better serve our members.

Drug formulary

This plan doesn’t have a formulary; it only includes medications that would be covered under Medicare Part B.

This plan has a drug formulary.

DME

DMEnsion Benefit Management will play the same role for our PFFS members as it does for our Medicare Plus Blue PPO members. The network and billing guidelines are the same and all out-of-network claims will be reimbursed using the CMS fee schedule.

PPO lab network

Our PFFS providers are encouraged to use the Medicare Advantage laboratory network established with Quest Diagnostics and Joint Venture Hospital Laboratories. The lab network provides non-patient clinical and anatomic pathology lab services to our Medicare Plus Blue PPO and Blue Cross Medicare PFFS members. By using this network, both our PPO and PFFS members avoid out-of-pocket costs.

Specialty care

Blue Cross Medicare PFFS members need to meet their annual deductible, but don’t have a higher copayment for specialty services.

Medicare Plus Blue PPO allows all individual members direct access to health specialists for in-network routine, preventive and specialty services. For most services, members will have a higher copayment when they see specialists rather than general care physicians. General care providers include general practice, family practice, geriatrics, internal medicine, obstetrics/gynecology, pediatrics, nurse practitioners and physician’s assistants.