BlueCHiP for Medicare Preferred

BlueCHiP for Medicare

Preferred

This plan offers one of our widest ranges of medical benefits, copays, coinsurance, and out-of-pocket maximum, plus out-of-network coverage.

$0 copay for PCMH PCP visits
$25 specialist visits
$0 labs/X-rays
$0 for routine hearing and vision screenings
$0 virtual doctors' visits 24/7
Out-of-network coverage
$0 drug deductible
$3 Tier 1 and $6 Tier 2 prescription copays at preferred pharmacies
Tier 1 & 2 gap coverage
$20 insulin copay (30-day supply) with Insulin Savings Program*
Dental coverage built-in
$100/quarter over-the-counter (OTC) benefit (Flexible Benefit Card)
$200/year allowance for dental, hearing, and vision (Flexible Benefit Card)
$0 fitness benefit
$0 rides
$0 peer recovery services
$75 emergency room copay
$75 ambulance copay
$150 outpatient surgery copay
Hearing aids for $200-$1,675 copay per ear in-network
$350 wig allowance
60 hours/year of household help

Need help?
Call 1-800-505-2583 (TTY: 711)

Monthly premium

$264^.00

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
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Medical & Hospital Benefits

Outpatient Care and Services^1,2

Ambulance

$75/trip

Dental Services

Medicare-covered:
In-network: 20% of the cost
Out-of-network: 20% of the cost
Preventive: $0
Comprehensive: $0
$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

In-network: $0
Out-of-network: 20% of the cost
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
$150 for high-tech radiology services (for example, MRIs)
Out-of-network: 20% of the cost

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.

Outpatient Hospital/Surgery

In-network: Up to $150 copay per visit
Out-of-network: 20% of the cost

Primary Care Physician Visit

In-network:
$0 PCMH or $5 non-PCMH copay per visit
Out-of-network: 20% of the cost

Specialist Visit

In-network: $25 copay per visit
Out-of-network: 20% of the cost
Referral is required for specialist visits.

Vision Visit

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

Non-routine vision:
In-network: $25 copay per visit
Out-of-network: 20% of the cost

Vision hardware:
$200/year allowance for dental, hearing, and vision (Flexible Benefit Card)

Hearing Services

Routine hearing:
In-network: $0
Out-of-network: 20% of the cost
Non-routine hearing:
In-network: $25 copay per visit
Out-of-network: 20% of the cost
Hearing aids:
$200-$1,675 copay per hearing aid (2 aids every 3 years)

Preventive Care

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

Inpatient Care^1,2

Inpatient Hospital Care

In-network: $180 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

Prescription Deductible

No deductible

Initial Coverage (up to 30-day supply)³

Tier 1 (Preferred Generic)

$3 copay

$11 copay

Tier 2 (Non-preferred Generic)

$6 copay

$14 copay

Tier 3 (Preferred Brand)

$47 copay

Tier 4 (Non-Preferred Drug)

$100 copay

Tier 5 (Specialty Tier)

33% of the cost

Mail Order (90-day Supply)

$0 copay for Tiers 1 and 2

Gap Coverage

$3 for Tier 1 and $6 for Tier 2

$11 for Tier 1 and $14 for Tier 2

Insulin Savings Program*

$20 (30 days)

Plan Documents

* The Insulin Savings Program is not available to members who qualify for a low-income subsidy (LIS).

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.