Medicare

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HMO-POS Network

2018 BlueCHiP for Medicare Preferred

This plan offers our widest range of medical benefits (including our highest vision hardware and hearing aid allowances); the lowest copayments, coinsurance, and out-of-pocket maximum; plus out-of-network coverage.

  • $0 copay for PCMH PCP visits/$5 copay for non-PCMH PCP visits
  • $150 outpatient surgery copay
  • $5/month fitness benefit
  • $200/year vision hardware allowance
  • $750 hearing aid allowance every 3 years
  • Optional dental rider available for an additional cost
  • Tier 1 & Tier 2 gap coverage for prescriptions

BlueCHiP for Medicare Preferred

Monthly Premium

$257.00

Max Out-of-Pocket

$2,250

PCP Copay

$0/$5

Prescriptions

Tier 1-$3

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What is covered?

COVERAGE TYPE
COPAYS & DETAILS OF COVERAGE

Medical and Hospital Benefits

Outpatient Care and Services


Ambulance1

$75/trip

Diabetes Supplies and Services1

Diabetes Monitoring Supplies:
In-Network: $0
Out-of-Network: 20% of the cost

Diagnostic Tests, Lab Services, and X-Rays1

Lab services and x-rays:
In-Network: $0
Out-of-Network: 20% of the cost

Emergency Care1

$65 copay

Hearing Services1

Routine hearing exam:
In-network: $30 copay
Out-of-network: 20% of the cost

Hearing aids:
$750 allowance every 3 years
 

Outpatient Surgery1

Outpatient hospital
In-network: $150 copay
Out-of-network: 20% of the cost

Primary Care Physician Visit1

In-network: $0 copay for PCMH providers/$5 copay for non-PCMH providers
Out-of-network: 20% of the cost

Radiology Services (MRIs, CT scan2)

In-Network: $150 copay
Out-of-Network: 20% of the cost

Specialist Visit1

In-network: $30 copay
Out-of-network: 20% of the cost

Vision Visit1

Routine & Diagnostic eye exam:
In-network: $30 copay
Out-of-network: 20% of the cost

Vision Hardware:
$200 allowance
 

Preventative Care


In-network: You pay nothing
Out-of-network: 20% of the cost

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

Out-of-network: 20% of the cost per stay

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

Out-of-network: 20% of the cost per stay

Prescription Drug Benefits

Initial Coverage (up to 30-day supply3)

Preferred
Standard

Tier 1 (Preferred Generic)

$3

$11

Tier 2 (Non-preferred Generic)

$6

$14

Tier 3 (Preferred Brand)

$47

$47

Tier 4 (Non-preferred Brand)

$100

$100

Tier 5 (Specialty Tier)

33%

33%

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.