Blue Advantage Complete (PPO) Medicare Advantage Plan H0104-012 • 2026 • Cleburne County, AL

Blue Advantage Complete Overview

Coverage Overview for Blue Advantage Complete

This MAPD PPO Medicare Advantage plan includes Medicare Part A and Part B services along with integrated prescription drug coverage. The monthly premium is $35.50, and the plan allows access to Medicare-approved providers, with lower costs when using in-network providers. The annual Part D deductible is $200.00.

Primary care visits have a $5 copay | Out-of-network: 50% coinsurance, and specialist visits come with a $30 copay | Out-of-network: 50% coinsurance. Urgent care services carry a $5-$30 copay, and ground ambulance transportation is $420 copay | Out-of-network: $420 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $5900.00. After this limit is reached, in-network services are fully covered.

This plan is recognized by CMS under Plan ID H0104-012. Cost-sharing details are outlined below.

Out-of-Pocket Costs

Blue Advantage Complete includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The table below outlines the most common in-network out-of-pocket costs associated with plan H0104-012.

Certain preventive services are covered 100% by Blue Advantage Complete as a Part B benefit.

Prescription Drug Coverage

Blue Advantage Complete includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Special Needs Plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $200.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Blue Cross and Blue Shield of Alabama starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, Blue Advantage Complete may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

CMS 5-Star Ratings

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.