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 fitness benefit
- $0 rides
- $0 virtual doctors’ visits 24/7
- $0 peer recovery services
- $5 labs/X-rays
- $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
See if your doctor and pharmacy are in the network
Copays & Details
Outpatient Care and Services1,2
Medicare-covered: 20% of the cost
Comprehensive: 20% of the cost for covered services
$1,500 limit on all covered dental services for preventive and comprehensive dental services. All preventive and comprehensive services must be provided by an in-network plan-contracted dentist.
Diabetes Supplies and Services
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 (for example, MRIs)
$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.
Routine hearing: $0
Non-routine hearing: $35 copay per visit
$200-$1,675 copay per hearing aid (2 aids every 3 years)
Up to $275 copay per visit
Primary Care Physician Visit
$0 PCMH or $20 non-PCMH copay per visit
$35 copay per visit
Referral is required for specialist visits.
Routine vision: $0
Non-routine vision: $35 copay per visit
Our plan pays up to $125 every year for eyewear
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.
$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)
Tier 2 (Non-preferred Generic)
Tier 3 (Preferred Brand)
Tier 4 (Non-Preferred Drug)
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 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, Initial Coverage stage, Coverage Gap stage and the Catastrophic level stage.