Monthly premium
Offering low out-of-pocket costs, the state’s largest Medicare Advantage network, and additional medical benefits like vision, hardware, and wig allowances, this plan provides comprehensive coverage to meet many needs.
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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
Prescription Drugs
- $0 drug deductible
- $3 Tier 1 and $6 Tier 2 prescription copays at preferred pharmacies
- $20 preferred insulin copay (30-day supply) or $50 (90-day). Copays will not increase, even through the coverage gap.*
Dental/Hearing/Vision
- $0 preventive and comprehensive dental
- $0 for routine hearing and vision screenings
- 2 hearing aids, starting at $0, annually
- $200 vision hardware allowance
- $280/year allowance for dental and hearing (Flexible Benefit Card)
Extras
- $100/quarter over-the-counter (OTC) benefit for everyday health items (Flexible Benefit Card)
- $0 fitness benefit
- $0 rides
- 40 hours/year of household help
- $350 wig allowance
Tools to help you choose:
See if your doctor and pharmacy are in the network
Ambulance
$75/trip
Dental Services
Medicare-covered: 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
$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
$150 for high-tech radiology services (for example, MRIs)
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
Up to $150 copay per visit
Hearing Services
Routine hearing
$0
Non-routine hearing
$25 copay per visit
Hearing aids
$0-$1,475 copay per hearing aid (2 aids every year)
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
$190 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
$135 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.
No deductible
Tier 1 (Preferred Generic)
$3 copay
$11 copay
Tier 2 (Non-preferred Generic)
$6 copay
$14 copay
Tier 3 (Preferred Brand)
$47 copay
$47 copay
Tier 4 (Non-preferred Drug)
$100 copay
$100 copay
Tier 5 (Specialty Tier)
33% of the cost
33% of the cost
Preferred Mail Order (90-day Supply)
$0 copay for Tiers 1 and 2
Preferred Insulins (30-day Supply)
$20
*$20 preferred insulin copay (30-day supply) or $50 (90-day) for preferred insulins on Tier 3. Tier 4 formulary insulins will have a $35 (30-day supply) or $105 (90-day) copay.
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.
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.