BlueCHiP for Medicare

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2018

HMO-POS Network

BlueCHiP for Medicare

Value

Monthly premium

$23.00 - $33.00

Max Out-of-Pocket

$5,900

PCP Copay

$5/$35

Prescriptions

Tier 1-$1

HMO Network

BlueCHiP for Medicare

Advance

Monthly premium

$0.00

Max Out-of-Pocket

$5,100

PCP Copay

$10

Prescriptions

Tier 1-$1

HMO-POS Network

BlueCHiP for Medicare

Extra

Monthly premium

$97.00

Max Out-of-Pocket

$3,750

PCP Copay

$0/$10

Prescriptions

Tier 1-$0

HMO Network

BlueCHiP for Medicare

Standard with Drugs

Monthly premium

$58.00

Max Out-of-Pocket

$4,500

PCP Copay

$0/$20

Prescriptions

Tier 1-$3

HMO Network

BlueCHiP for Medicare

Plus

Monthly premium

$168.00

Max Out-of-Pocket

$2,800

PCP Copay

$0/$5

Prescriptions

Tier 1-$3

HMO-POS Network

BlueCHiP for Medicare

Preferred

Monthly premium

$257.00

Max Out-of-Pocket

$2,250

PCP Copay

$0/$5

Prescriptions

Tier 1-$3

HMO Network

BlueCHiP for Medicare

Core

Monthly premium

$0.00

Max Out-of-Pocket

$3,950

PCP Copay

$0/$10

Prescriptions

Not Covered