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
  • $0/month fitness benefit
  • $0 rides to your PCP/specialist visits
  • $0 Virtual doctors’ visits 24/7
  • $0 Labs/Xrays
  • $30 Specialist visits
  • $50/quarter Over the Counter (OTC) benefit
  • $150/year vision hardware allowance
  • $150 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

$0 for Lab services
$0 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: $30 copay per visit
Hearing aids:
$200-$1,675 copay per hearing aid (2 aids every 3 years)

Outpatient Hospital/Surgery

$150 copay per visit

Primary Care Physician Visit

$0 PCMH or $5 non-PCMH copay per visit

Specialist Visit

$30 copay per visit
Referral is required for specialist visits.

Vision Visit

Routine vision: $0
Non-routine vision: $30 copay per visit
Vision hardware:
Our plan pays up to $150 every year for eyewear

Preventive Care

$0

Inpatient Care1,2

Inpatient Hospital Care

$180 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
$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, 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.

2020
Core
BlueCHiP for Medicare
BlueCHiP for Medicare Core
HMO
1
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