Medicare

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HMO Network

2018 BlueCHiP for Medicare Core

With a $0 monthly premium, this is a sensible option for those who want a comprehensive plan without prescription drug coverage and low predictable out-of-pocket costs.

  • $0 monthly premium
  • $0 copay for PCMH PCP visits/$10 copay for non-PCMH PCP visits
  • $5/month fitness benefit
  • $100/year vision hardware allowance
  • Optional dental rider available for an additional cost

BlueCHiP for Medicare Core

Monthly Premium

$0.00

Max Out-of-Pocket

$3,950

PCP Copay

$0/$10

Prescriptions

Not Covered

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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

Diabetes Monitoring Supplies:
In-Network: $0

Diagnostic Tests, Lab Services, and X-Rays1

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

Emergency Care1

$75 copay

Hearing Services1

Routine hearing exam:
In-network: $40 copay

Hearing aids:
In-network: Not Covered

Outpatient Surgery1

Outpatient hospital
In-network: 20% of the cost

Primary Care Physician Visit1

In-network: $0 copay for PCMH providers/$10 copay for non-PCMH providers

Radiology Services (MRIs, CT scan2)

In-Network: $150 copay

Specialist Visit1

In-network: $40 copay

Vision Visit1

Routine & Diagnostic eye exam:
In-network: $40 copay

Vision Hardware:
In-network: $100 allowance

Preventative Care


In-network: You pay nothing

Inpatient Care


Inpatient Hospital Care1

In-network: $180 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; $130 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

 

Not Covered

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.