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
  • $0 for routine hearing and vision screenings
  • $5/month fitness benefit
  • $100/year vision hardware allowance
  • Optional dental rider available for an additional cost
  • Virtual doctors’ visits 24/7

Monthly premium

$0.00


Customize this plan with Dental coverage for $21.60 per month.
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What's covered

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Medical & Hospital Benefits

Coverage

Copays & Details

Outpatient Care and Services1,2

Ambulance

$150/trip

Dental Services

Medicare-covered: 20% of the cost

Diabetes Supplies and Services

$0
You must use OneTouch plan designated monitors and test strips

Diagnostic Tests, Lab and Radiology Services, and X-Rays

$0 for Lab services
$0 for Diagnostic tests and X-Rays
$150 for High tech radiology services

Emergency Care

$90 copay per visit
If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care

Hearing Services

Routine hearing: $0
Non-routine hearing: $40 copay per visit

Outpatient Hospital/Surgery

20% of the cost

Primary Care Physician Visit

$0 PCMH or $10 non-PCMH copay per visit

Specialist Visit

$40 copay per visit
Referral is required for specialist visits

Vision Visit

Routine vision: $0
Non-routine vision: $40 copay per visit

Vision hardware:
Our plan pays up to $100 every year for eyewear.

Preventive Care

$0

Inpatient Care1,2

Inpatient Hospital Care

$180 copay per day for days 1-5
Our plan covers an unlimited number of days for an inpatient hospital stay

Skilled Nursing Facility

$0 copay per day for days 1-20
$130 copay per day for days 21-45
$0 copay per day for days 46-100
Our plan covers up to 100 days in a SNF

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 A preauthorization may be required. 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.

2019
Core
BlueCHiP for Medicare

This information is not a complete description of benefits. Call the Medicare sales team at 1-800-505-BLUE (2583) (TTY: 711) for more information.