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/X-rays
  • $0 fitness benefit
  • $0 rides
  • $0 drug deductible
  • $0 Tier 1 and Tier 2 prescription copays at preferred pharmacies
  • Tier 1 & 2 gap coverage
  • $0 virtual doctors’ visits 24/7
  • $0 peer recovery services
  • $15 acupuncture benefit
  • $25 specialist visits
  • $50 caregiver reimbursement
  • $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 fitness tracker
  • $2,000 dental benefit
  • $4,000 combined in- and out-of-network out-of-pocket max

Monthly premium

$110.00


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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 & 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 (for example, MRIs)
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

$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: $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: Up to $250 copay per visit
Out-of-network: Up to $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: $25

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 Drug)

n/a

$100 copay

Tier 5 (Specialty Tier)

n/a

33% of the cost

Mail Order (90-day Supply)

n/a

Gap Coverage

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 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.

2021
PPO
HealthMate for Medicare
HealthMate for Medicare PPO
PPO
0

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