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HMO-POS Network

BlueCHiP for Medicare

Value

Monthly premium

$0^.00

Max Out-of-Pocket

$5,000

PCP Copay

$0/$10

Prescriptions

$0 - Tiers 1 and 2

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PPO Network

HealthMate for Medicare

PPO

Monthly premium

$143^.00

Max Out-of-Pocket

$5,000 combined

PCP Copay

$0/$10

Prescriptions

$0 - Tiers 1 and 2

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HMO-POS Network

BlueCHiP for Medicare

Extra

Monthly premium

$105^.00

Max Out-of-Pocket

$4,500

PCP Copay

$0/$5

Prescriptions

$0 - Tier 1; $4 - Tier 2

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HMO Network

BlueCHiP for Medicare

Standard with Drugs

Monthly premium

$55^.00

Max Out-of-Pocket

$4,500

PCP Copay

$0/$10

Prescriptions

$0 - Tiers 1 and 2

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HMO Network

BlueCHiP for Medicare

Plus

Monthly premium

$130^.00

Max Out-of-Pocket

$2,800

PCP Copay

$0/$5

Prescriptions

$3 - Tier 1; $6 - Tier 2

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HMO-POS Network

BlueCHiP for Medicare

Preferred

Monthly premium

$237^.00

Max Out-of-Pocket

$2,250

PCP Copay

$0/$5

Prescriptions

$3 - Tier 1; $6 - Tier 2

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HMO Network

BlueCHiP for Medicare

Core

Monthly premium

$0^.00

Max Out-of-Pocket

$3,500

PCP Copay

$0/$5

Prescriptions

Not Covered

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