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
  • $0/month fitness benefit
  • $0 rides to your PCP/specialist visits
  • $0 Virtual doctors’ visits 24/7
  • $0 Labs/Xrays
  • $0 Drug deductible
  • $0 Tier 1 and $4 Tier 2 prescription copays at preferred pharmacies
  • $20 acupuncture benefit
  • $25 Specialist visits
  • $150/year vision hardware allowance
  • $100/quarter Over the Counter (OTC) benefit
  • $200 annual wellness reimbursement
  • Flat dollar Outpatient surgery copay
  • One Max Buzz fitness tracker
  • Dental coverage built in
  • Out-of-network coverage

Monthly premium

$99.00


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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:
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. All preventative and comprehensive services must be provided by an in network plan contracted dentist.

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
$125 for High tech radiology services (Ex. MRI's)
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:
$200-$1,675 copay per hearing aid (2 aids every 3 years)

Outpatient Hospital/Surgery

In-network: $250 copay per visit
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: $275 copay per day for days 1-5 $0 Days 6+
Out-of-network: 20% of the cost
Our plan covers an unlimited number of days for an in-network 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)

$4 copay

$12 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, 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
Extra
BlueCHiP for Medicare
BlueCHiP for Medicare Extra
HMO-POS
0
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