Medicare

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HMO Network

2018 BlueCHiP for Medicare Advance

A $0 premium plan that gives you a seamless healthcare experience, with highly coordinated care from a local provider network. This plan uses a network of PCPs, specialists, hospitals and information systems to deliver an innovative experience at lower costs to keep you healthier.

  • $0 monthly premium
  • $10 PCP visit copay
  • $100/year vision hardware allowance
  • $1 Tier 1 and $8 Tier 2 prescription copays at preferred pharmacies
  • Optional dental rider available for an additional cost

BlueCHiP for Medicare Advance

Monthly Premium

$0.00

Max Out-of-Pocket

$5,100

PCP Copay

$10

Prescriptions

Tier 1-$1

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What is covered?

COVERAGE TYPE
COPAYS & DETAILS OF COVERAGE

Medical and Hospital Benefits

Outpatient Care and Services


Ambulance1

$150/trip

Diabetes Supplies and Services1,5

Diabetes Monitoring Supplies:
In-Network: $0

Diagnostic Tests, Lab Services, and X-Rays1

Lab services
In-Network: $12

X-rays, diagnostic tests and procedures
In-Network: $15

Emergency Care1

$75 copay

Hearing Services1,5

Routine hearing exam:
In-network: $45 copay

Hearing aids:
In-network: Not Covered

Outpatient Surgery1,5

Outpatient hospital
In-network: 20% of the cost

Primary Care Physician Visit1

In-network: $10 copay

Radiology Services (MRIs, CT scan2)

In-Network: $200 copay

Specialist Visit1,5

In-network: $45 copay

Vision Visit1,5

Routine & Diagnostic eye exam:
In-network: $45 copay

Vision Hardware:
In-network: $100 allowance

Preventative Care


In-network: You pay nothing

Inpatient Care


Inpatient Hospital Care1

In-network: $360 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; $155 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)

Preferred
Standard

Tier 1 (Preferred Generic)

$1

$9

Tier 2 (Non-preferred Generic)

$8

$16

Tier 3 (Preferred Brand)

$47

$47

Tier 4 (Non-preferred Brand)

$100

$100

Tier 5 (Specialty Tier)

29%

29%

Deductible4

$200

$200

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.

4 Deductible applies to tiers 3, 4, and 5.

5Service may require a referral from your doctor