Monthly premium
Designed for those who are on a tight budget and who have minimal health needs. This plan requires higher out-of-pocket costs when care is needed. It has a Part B deductible.
Not sure what plan you need? Use the plan recommendation tool.
Medical
- $160 annual Part B deductible
- $0 PCP visits after deductible
- $0-$50 specialist visits after deductible
- $0 labs after deductible
- $25 X-rays after deductible
- $0-$50 physical/speech/occupational therapy after deductible
- Out-of-network coverage
Prescription Drugs
- $615 pharmacy deductible (Tiers 3-5)
- $0 Tier 1 prescription copay
- $2 Tier 2 prescription copay
Dental/Vision/Hearing
- $500/year dental benefit maximum
- $0 cost preventive dental
- No coverage for comprehensive dental (fillings, root canals, crowns)
- $0 cost annual vision exam
- $100/year eyewear allowance
- $0 cost annual hearing exam
- No coverage for hearing aids
Extras
- $0-$40 fitness center membership
- No over-the-counter (OTC) allowance
Qualify for a Low-Income Subsidy (Extra Help)?
See if your doctor and pharmacy are in the network
Part B deductible
$160/year
Ambulance
$200/trip after deductible
Dental Services
Medicare-covered
In-network: 20% of the cost
Out-of-network: 40% of the cost
Preventive: $0
Comprehensive: Not Covered
$500 limit on all covered preventative dental services. All preventative 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 after deductible
$25 for X-Rays after deductible
$50 for Diagnostic tests after deductible
$0-$250 for High tech radiology services (Ex. MRIs) after deductible
Out-of-network
40% 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: 40% of the cost
Non-routine hearing
In-network: $50 copay per visit
Out-of-network: 40% of the cost
Outpatient Hospital/Surgery
In-network
Up to $450 copay per visit for ambulatory surgical center-based services after deductible
Up to $550 copay per visit for hospital-based services after deductible
Out-of-network
40% of the cost
Primary Care Provider Visit
In-network
$0 PCP copay per visit after deductible
Out-of-network
40% of the cost
Specialist Visit
In-network
$0-$50 copay per visit after deductible
Out-of-network
40% of the cost
Referral is required for specialist visits.
Vision Visit
Routine vision
In-network: $0
Out-of-network: 40% of the cost
Non-routine vision
In-network: $50 copay per visit
Out-of-network: 40% of the cost
Vision hardware
Our plan offers a $100/year allowance for vision hardware.
Preventive Care
In-network
$0
Out-of-network
40% of the cost
Inpatient Hospital Care
In-network
$458 copay per day for days 1-6
$0 Days 7+
Out-of-network
40% 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 21-100
Out-of-network
40% of the cost
Our plan covers up to 100 days in a SNF.
Prescription Deductible
$615 (tiers 3-5)
Tier 1 (Preferred Generic)
$0 copay
$0 copay
Tier 2 (Non-preferred Generic)
$2 copay
$0 copay
Tier 3 (Preferred Brand)
25% coinsurance
25% coinsurance
Tier 4 (Non-preferred Drug)
30% coinsurance
30% coinsurance
Tier 5 (Specialty Tier)
25% coinsurance
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.