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HMO Network

2018 BlueCHiP for Medicare Plus

Offering low out-of-pocket costs with additional medical benefits like vision hardware and hearing aid allowances, this plan provides comprehensive coverage to meet many needs.

  • $0 copay for PCHM PCP visits/$5 copay for non-PCMH PCP visits
  • $150 outpatient surgery copay
  • $5/month fitness benefit
  • $150/year vision hardware allowance
  • $500 hearing aid allowance every 3 years
  • Optional dental rider available for an additional cost
  • $3 Tier 1 and $6 Tier 2 prescription copays at preferred pharmacies

BlueCHiP for Medicare Plus

Monthly Premium


Max Out-of-Pocket


PCP Copay



Tier 1-$3

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Come back at the start of the Annual Enrollment Period (October 15) to select and enroll in a plan.

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What is covered?


Medical and Hospital Benefits

Outpatient Care and Services



Diabetes Supplies and Services1

Diabetes Monitoring Supplies:
In-Network: $0

Diagnostic Tests, Lab Services, and X-Rays1

Lab services and x-rays:
In-Network: $0

Emergency Care1

$65 copay

Hearing Services1

Routine hearing exam:
In-network: $30 copay

Hearing aids:
In-network: $500 allowance every 3 years

Outpatient Surgery1

Outpatient hospital
In-network: $150 copay

Primary Care Physician Visit1

In-network: $0 copay for PCMH providers/$5 copay for non-PCMH providers

Radiology Services (MRIs, CT scan2)

In-Network: $150 copay

Specialist Visit1

In-network: $30 copay

Vision Visit1

Routine & Diagnostic eye exam:
In-network: $30 copay

Vision Hardware:
In-network: $150 allowance

Preventative Care

In-network: You pay nothing

Inpatient Care

Inpatient Hospital Care1

In-network: $190 copay per day for days 1 through 5; You pay nothing per day for days 6 through 90; You pay nothing per day for days 91 and beyond

Skilled Nursing Facility1

In-network: You pay nothing per day for days 1 through 20; $135 copay per day for days 21 through 45; You pay nothing per day for days 46 through 100

Prescription Drug Benefits

Initial Coverage (up to 30-day supply3)


Tier 1 (Preferred Generic)



Tier 2 (Non-preferred Generic)



Tier 3 (Preferred Brand)



Tier 4 (Non-preferred Brand)



Tier 5 (Specialty Tier)



Mail order (90-day supply)

$0 for Tiers 1 and 2

1 The out-of-pocket maximum includes only Medicare-covered services. This is the most a member would pay for these services during a calendar year. You must receive all routine care from plan providers unless you select the BlueCHiP for Medicare Value (HMO-POS), BlueCHiP for Medicare Extra, or BlueCHiP for Medicare Preferred (HMO-POS) plan. If you select the BlueCHiP for Medicare Value, BlueCHiP for Medicare Extra, or BlueCHiP for Medicare Preferred plan, with the exception of emergency or urgent care, ambulance, or dialysis services, it may cost more to get care from out-of-network providers.

2 Review may include but is not limited to pre-authorization and/or continued treatment by the plan and/or plan designee. Contact Plan for details.

3 Please refer to the Summary of Benefits or Chapter 6 of the Evidence of Coverage for prescription drug cost share information in a long-term care setting, mail order and extended day retail supplies as well as detailed benefit information concerning the Deductible stage (if applicable), Initial Coverage stage, Coverage Gap stage and the Catastrophic level stage. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, quantity limitations and restrictions may apply.