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
  • $0 for routine hearing and vision screenings
  • $0/month fitness benefit
  • $0 rides to your PCP/specialist visits
  • $0 Virtual doctors’ visits 24/7
  • $5 PCP visit copay
  • $5 Labs/Xrays
  • $25/quarter Over the Counter (OTC) benefit
  • $100/year vision hardware allowance
  • $2 Tier 1 and $9 Tier 2 prescription copays at preferred pharmacies
  • Flat dollar Outpatient surgery copay
  • Optional dental rider available for an additional cost

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

$5 for Lab services
$5 for Diagnostic tests and X-Rays
$150 for High tech radiology services (Ex. MRI's)

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
Hearing aids:
$200-$1,675 copay per hearing aid (2 aids every 3 years)

Outpatient Hospital/Surgery

$350 copay per visit

Primary Care Physician Visit

$5 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

$360 copay per day for days 1-5. $0 Days 6+
Our plan covers an unlimited number of days for an inpatient hospital stay.

Skilled Nursing Facility

$0 copay per day for days 1-20
$160 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.

Prescription Drug Benefits

Preferred

Standard

Prescription Deductible

$0 per year for Tier 1 and Tier 2
$200 for Tier 3, Tier 4, and Tier 5 Part D prescription drugs

Initial Coverage (up to 30-day supply)3

Tier 1 (Preferred Generic)

$2 copay

$10 copay

Tier 2 (Non-preferred Generic)

$9 copay

$17 copay

Tier 3 (Preferred Brand)

$47 copay

$47 copay

Tier 4 (Non-preferred Brand)

$100 copay

$100 copay

Tier 5 (Specialty Tier)

29% of the cost

29% 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, BlueCHiP for Medicare Preferred (HMO-POS), or the HealthMate for Medicare (PPO) plan. If you select the BlueCHiP for Medicare Value, BlueCHiP for Medicare Extra, BlueCHiP for Medicare Preferred, or the HealthMate for Medicare 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.

2020
Advance
BlueCHiP for Medicare
BlueCHiP for Medicare Advance
HMO
1
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