BlueCHiP for Medicare
Core
Monthly premium
$0.00
With a $0 monthly premium, this is a sensible option for those who want a comprehensive plan without prescription drug coverage and low, predictable out-of-pocket costs.
Medical
- $0 copay for PCMH PCP visits
- $0 labs/X-rays
- $0 virtual doctors' visits 24/7
- $25 specialist visits
- Flat dollar outpatient surgery copay
Dental/Hearing/Vision
- $0 preventive and comprehensive dental
- $0 for routine hearing and vision screenings
- 2 hearing aids, starting at $200, annually
- $200 vision hardware allowance
- $200/year allowance for dental and hearing (Flexible Benefit Card)
Extras
- $75/quarter over-the-counter (OTC) benefit for everyday health items (Flexible Benefit Card)
- $0 fitness benefit
- $0 rides
- 40 hours/year of household help
What's covered
See if your doctor is in the network
Ambulance
$150/trip
Dental Services
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
$0
You must use OneTouch plan-designated monitors and test strips.
Diagnostic Tests, Lab and Radiology Services, and X-rays
$0 for lab services
$0 for diagnostic tests and X-rays
$130 for high-tech radiology services (for example, MRIs)
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
$0
Non-routine hearing
$25 copay per visit
Hearing aids
$200-$1,675 copay per hearing aid (2 aids every year)
Outpatient Hospital/Surgery
Up to $150 copay per visit
Primary Care Provider Visit
$0 PCMH or $5 non-PCMH copay per visit
Specialist Visit
$25 copay per visit
Referral is required for specialist visits.
Vision Visit
Routine vision
$0
Non-routine vision
$25 copay per visit
Vision hardware
Our plan offers a $200/year allowance for vision hardware.
Preventive Care
$0
Inpatient Hospital Care
$180 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 (SNF)
$0 copay per day for days 1-20
$130 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.
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 (HMO-POS), 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.