BlueCHiP for Medicare

Standard with Drugs

One of our original BlueCHiP for Medicare plans that offers comprehensive coverage and many extras, like a fitness benefit and a vision hardware allowance, all for a low 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
  • $5 Labs/Xrays
  • $75/quarter Over the Counter (OTC) benefit
  • $125/year vision hardware allowance
  • Dental coverage built in
  • $1 Tier 1 and $8 Tier 2 prescription copays at preferred pharmacies
  • Flat dollar Outpatient surgery copay

Monthly premium

$65.00


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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: 20% of the cost
Preventive: $0
Comprehensive: 20% of the cost for covered services
$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

$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
$125 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: $35 copay per visit
Hearing aids:
$200-$1,675 copay per hearing aid (2 aids every 3 years)

Outpatient Hospital/Surgery

$275 copay per visit

Primary Care Physician Visit

$0 PCMH or $20 non-PCMH copay per visit

Specialist Visit

$35 copay per visit
Referral is required for specialist visits.

Vision Visit

Routine vision: $0
Non-routine vision: $35 copay per visit

Vision Hardware:
Our plan pays up to $125 every year for eyewear

Preventive Care

$0

Inpatient Care1,2

Inpatient Hospital Care

$290 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
$140 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
$100 for Tier 3, Tier 4, and Tier 5 Part D prescription drugs

Initial Coverage (up to 30-day supply)3

Tier 1 (Preferred Generic)

$1 copay

$9 copay

Tier 2 (Non-preferred Generic)

$8 copay

$16 copay

Tier 3 (Preferred Brand)

$47 copay

$47 copay

Tier 4 (Non-preferred Brand)

$100 copay

$100 copay

Tier 5 (Specialty Tier)

31% of the cost

31% 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
Standard with Drugs
BlueCHiP for Medicare
BlueCHiP for Medicare Standard with Drugs
HMO
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