BlueCHiP for Medicare

Extra

This plan accommodates your busy, active lifestyle, offering flexible coverage even outside of our network, plus many advantages like a fitness benefit, low PCP copays, and a low out-of-pocket maximum.

  • $0 copay for PCMH PCP visits
  • $0 for routine hearing and vision screenings
  • $5/month fitness benefit
  • $100/quarter Over the Counter (OTC) benefit
  • $150/year vision hardware allowance
  • Dental coverage built in
  • Out-of-network coverage
  • No pharmacy deductible
  • $0 Tier 1 and $5 Tier 2 prescription copays at preferred pharmacies
  • Virtual doctors’ visits 24/7

Monthly premium

$99.00


Enroll now
Submit Plan Change

Come back at the start of the Annual Election Period (October 15) to select and enroll in a plan.

Already a member and want to make a change?
Continue here


What's covered

See if your doctor and pharmacy are in the network
Search providers

Medical & Hospital Benefits

Coverage

Copays & Details

Outpatient Care and Services1,2

Ambulance

$150/trip

Dental Services

Medicare-covered:
In-network: 20% of the cost
Out-of-network: 20% of the cost
Preventive: $0
Comprehensive: $0
$1,500 limit on all covered dental services for Preventive and Comprehensive Dental Services

Diabetes Supplies and Services

In-network: $0
Out-of-network: 20% of the cost
You must use OneTouch plan designated monitors and test strips

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

In-network:
$0 for Lab services
$0 for Diagnostic tests and X-Rays
$100 for High tech radiology services
Out-of-network: 20% of the cost

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:
In-network: $0
Out-of-network: 20% of the cost

Non-routine hearing:
In-network: $25 copay per visit
Out-of-network: 20% of the cost

Hearing aids:
Not Covered

Outpatient Hospital/Surgery

In-network: 20% of the cost
Out-of-network: 20% of the cost

Primary Care Physician Visit

In-network:
$0 PCMH or $10 non-PCMH copay per visit
Out-of-network: 20% of the cost

Specialist Visit

In-network: $25 copay per visit
Out-of-network: 20% of the cost
Referral is required for specialist visits

Vision Visit

Routine vision:
In-network: $0
Out-of-network: 20% of the cost

Non-routine vision:
In-network: $25 copay per visit
Out-of-network: 20% of the cost

Vision Hardware:
Our plan pays up to $150 every year for eyewear

Preventive Care

In-network: $0
Out-of-network: 20% of the cost

Inpatient Care1,2

Inpatient Hospital Care1

In-network: $250 copay per day for days 1-5
Out-of-network: 20% of the cost
Our plan covers an unlimited number of days for an inpatient hospital stay

Skilled Nursing Facility

In-network:
$0 copay per day for days 1-20
$135 copay per day for days 21-45
$0 copay per day for days 46-100
Out-of-network: 20% of the cost
Our plan covers up to 100 days in a SNF

Prescription Drug Benefits

Preferred

Standard

Prescription Deductible

No deductible

Initial Coverage (up to 30-day supply)3

Tier 1 (Preferred Generic)

$0 copay

$8 copay

Tier 2 (Non-preferred Generic)

$5 copay

$13 copay

Tier 3 (Preferred Brand)

$47 copay

$47 copay

Tier 4 (Non-preferred Brand)

$100 copay

$100 copay

Tier 5 (Specialty Tier)

33% of the cost

33% of the cost

Mail Order (90-day Supply)

$0 copay 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 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.

3 You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances, quantity limitations and restrictions may apply. Please refer to the Summary of Benefits or 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.

2019
Extra
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.