HealthMate for Medicare

PPO

This plan offers the freedom to choose the providers and pharmacists you see. The flexibility of having your health insurance travel with you when you travel nationwide. The most comprehensive benefits with your health in mind.

  • No Referrals
  • Open Pharmacy Network
  • National Blue Cross & Blue Shield PPO network
  • $0 copay for PCMH PCP visits
  • $0 for routine hearing and vision screenings
  • $0 Labs/Xrays
  • $0/month fitness benefit
  • $0 rides to your PCP/specialist visits
  • $0 Drug deductible
  • $0 Tier 1 and $0 Tier 2 prescription copays at preferred pharmacies
  • Tier 1 & 2 Gap coverage
  • $0 Virtual doctors’ visits 24/7
  • $20 acupuncture benefit
  • $25 Specialist visits
  • $100/quarter Over the Counter (OTC) benefit
  • $200/year vision hardware allowance
  • $200 annual wellness reimbursement
  • Flat dollar Outpatient surgery copay
  • Flat dollar copays on most Out of network services
  • One Max Buzz fitness tracker
  • $2,000 dental benefit
  • $4,000 combined in/out of network max

Monthly premium

$110.00


Enroll now
Enroll Now

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


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
Preventative & Comprehensive:
In-network: $0
Out-of-network: 50% of the cost
$2,000 limit on all covered dental services for Preventive and Comprehensive Dental Services.

Diabetes Supplies and Services

In-network: $0
Out-of-network: $25 copay
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 (Ex. MRI's)
Out-of-network:
$10 for Lab services
$10 for Diagnostic tests and X-Rays
$200 for High tech radiology services (Ex. MRI's)

Emergency Care

$75 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: $50 copay per visit
Non-routine hearing:
In-network: $25 copay per visit
Out-of-network: $50 copay per visit
Hearing aids:
In-network: $200-$1,675 copay per hearing aid (2 aids every 3 years)
Out-of-network: 50% coinsurance for hearing aids and visits up to $300 per ear (2 aids every 3 years)

Outpatient Hospital/Surgery

In-network: $250 copay per visit
Out-of-network: $500 copay per visit

Primary Care Physician Visit

In-network: $0 PCMH or $10 non-PCMH copay per visit
Out-of-network: $25 copay per visit

Specialist Visit

In-network: $25 copay per visit
Out-of-network: $50 copay per visit

Vision Visit

Routine vision:
In-network: $0
Out-of-network: $50 copay per visit
Non-routine vision:
In-network: $25 copay per visit
Out-of-network: $50 copay per visit
Vision hardware:
Our plan pays up to $200 every year for eyewear

Preventive Care

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

Inpatient Care1,2

Inpatient Hospital Care

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
$130 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)

n/a

$0 copay

Tier 2 (Non-preferred Generic)

n/a

$0 copay

Tier 3 (Preferred Brand)

n/a

$47 copay

Tier 4 (Non-preferred Brand)

n/a

$100 copay

Tier 5 (Specialty Tier)

n/a

33% of the cost

Mail Order (90-day Supply)

n/a

$0 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
PPO
HealthMate for Medicare
HealthMate for Medicare PPO
PPO
0
BCBSRI Logo - Feedback Survey

Tell us what you really think

It only takes a moment and your feedback can help us provide better service to you in the future.

Feedback