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HMO-POS Network
BlueCHiP for Medicare
Value
Monthly premium
$0.00
Max Out-of-Pocket
$5,000
PCP Copay
$0/$35
Prescriptions
Tier 1-$0
PPO Network
HealthMate for Medicare
PPO
Monthly premium
$110.00
Max Out-of-Pocket
$4,000 combined
PCP Copay
$0/$10
Prescriptions
Tier 1-$0
HMO-POS Network
BlueCHiP for Medicare
Extra
Monthly premium
$99.00
Max Out-of-Pocket
$4,125
PCP Copay
$0/$10
Prescriptions
Tier 1-$0
HMO Network
BlueCHiP for Medicare
Advance
Monthly premium
$0.00
Max Out-of-Pocket
$5,000
PCP Copay
$0
Prescriptions
Tier 1-$2
HMO Network
BlueCHiP for Medicare
Standard with Drugs
Monthly premium
$61.00
Max Out-of-Pocket
$4,500
PCP Copay
$0/$20
Prescriptions
Tier 1-$1
HMO Network
BlueCHiP for Medicare
Plus
Monthly premium
$161.00
Max Out-of-Pocket
$2,800
PCP Copay
$0/$5
Prescriptions
Tier 1-$3
HMO-POS Network
BlueCHiP for Medicare
Preferred
Monthly premium
$266.00
Max Out-of-Pocket
$2,250
PCP Copay
$0/$5
Prescriptions
Tier 1-$3
HMO Network
BlueCHiP for Medicare
Core
Monthly premium
$0.00
Max Out-of-Pocket
$3,500
PCP Copay
$0/$5
Prescriptions
Not Covered
