Monthly premium
For people who need a moderate amount of medical care and want lower copays for specialists, increased coverage amounts for dental and vision, and an over-the-counter benefit to help pay for everyday health items
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Medical
- $0 Part B deductible
- $0 PCP visits
- $0-$40 specialist visits
- $0 labs
- $25 X-rays
- $0-$40 physical/speech/occupational therapy
- Out-of-network coverage
Prescription Drugs
- $500 pharmacy deductible (Tiers 3-5)
- $0 Tier 1 and Tier 2 prescription copays
Dental/Vision/Hearing
- $2,000/year dental benefit maximum
- $0 cost preventive and comprehensive dental
- No coverage for crowns
- $0 cost annual vision exam
- $200/year eyewear allowance
- $0 cost annual hearing exam
- Hearing aid coverage starting at $300 per ear
Extras
- $0-$20 fitness center membership
- Get $25/quarter over-the-counter (OTC) benefit for everyday health items
See if your doctor and pharmacy are in the network
Ambulance
$200 copay per trip
Dental Services
Medicare-covered:
In-network: 20% of the cost
Out-of-network: 30% of the cost
Preventive: $0
Comprehensive: $0
$2,000 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
You must use Abbott plan-designated monitors and test strips.
Diagnostic Tests, Lab and Radiology Services, and X-rays
In-network
$0 for lab services
$25 for X-rays
$50 for diagnostic tests
$0-$200 for high-tech radiology services (like MRIs)
Out-of-network
30% of the cost
Emergency Care
$130 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: 30% of the cost
Non-routine hearing:
In-network: $40 copay per visit
Out-of-network: 30% of the cost
Hearing aids:
$300-$1,775 copay per hearing aid (2 aids every year)
Outpatient Hospital/Surgery
In-network:
Up to $350 copay per visit for ambulatory surgical center based services.
Up to $450 copay per visit for hospital based services.
Out-of-network:
30% of the cost
Primary Care Provider Visit
In-network:
$0 PCP copay per visit
Out-of-network:
30% of the cost
Specialist Visit
In-network: $0-$40 copay per visit
Out-of-network: 30% of the cost
Referral is required for specialist visits.
Vision Visit
Routine vision:
In-network: $0
Out-of-network: 30% of the cost
Non-routine vision:
In-network:
$40 copay per visit
Out-of-network: 30% of the cost
Vision hardware:
Our plan offers a $200/year allowance for vision Hardware.
Preventive Care
In-network: $0
Out-of-network: 30% of the cost
Inpatient Hospital Care
In-network
$400 copay per day for days 1-6
$0 Days 7+
Out-of-network: 30% of the cost
Our plan covers an unlimited number of days for an in-network inpatient hospital stay.
Skilled Nursing Facility (SNF)
In-network:
$10 copay per day for days 1-20
$218 copay per day for days 21-45
$0 copay per day for days 46-100
Out-of-network:
30% of the cost
Our plan covers up to 100 days in a SNF.
Prescription Deductible
$500 (tiers 3-5)
Tier 1 (Preferred Generic)
$0 copay
$0 copay
Tier 2 (Non-preferred Generic)
$0 copay
$0 copay
Tier 3 (Preferred Brand)
25% coinsurance
25% coinsurance
Tier 4 (Non-preferred Drug)
30% coinsurance
30% coinsurance
Tier 5 (Specialty Tier)
27% of the cost
N/A
Insulins (30-day Supply)
$35 copay
1The 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 Essential (HMO-POS), BlueCHiP for Medicare Enhanced (HMO-POS) BlueCHiP for Medicare Extra (HMO-POS), or the BlueCHiP for Medicare Access (HMO-POS) plan. If you select the BlueCHiP for Medicare Essential (HMO-POS), BlueCHiP for Medicare Enhanced (HMO-POS), BlueCHiP for Medicare Extra (HMO-POS), or the BlueCHiP for Medicare Access (HMO-POS) 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.
2A 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.
3You 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 Summary of Benefits or 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 Initial Coverage stage and the Catastrophic level stage.