Monthly premium
The Preferred (HMO-POS) plan offers one of our widest ranges of medical benefits, copays, coinsurance, and out-of-pocket maximum, plus out-of-network coverage.
Not sure what plan you need? Use the plan recommendation tool.
Medical
- $0 copay for PCP visits
- $0 labs/X-rays
- $25 specialist visits
- Out-of-network coverage
Prescription Drugs
- $0 drug deductible
- $3 Tier 1 and $6 Tier 2 prescription copays
- Discounted copays for a 100-day supply with Preferred Mail Order
Dental/Hearing/Vision
- $0 preventive and comprehensive dental
- $1,500/year dental benefit maximum
- $0 for routine hearing and vision screenings
- 2 hearing aids, starting at $0, annually
- Get $280/year for dental and hearing (Flexible Benefit Card)
- Get $200/year for eyewear
Extras
- $0 gym and home fitness benefit
- Get $100/quarter over-the-counter (OTC) benefit for everyday health items (Flexible Benefit Card)
- Get $350 wig allowance
Tools to help you choose:
See if your doctor and pharmacy are in the network
Ambulance
$175 copay per trip
Dental Services
Medicare-covered
In-network: 20% of the cost
Out-of-network: 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
In-network: $0
Out-of-network: 20% of the cost
You must use OneTouch plan-designated monitors and test strips.
Diagnostic Tests, Lab and Radiology Services, and X-rays
In-network
$0 for lab services
$0 for diagnostic tests and X-rays
$175 for high-tech radiology services (for example, MRIs)
Out-of-network
20% of the cost
Emergency Care
$125 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
In-network
Up to $150 copay per visit for ambulatory surgical center based services.
Up to $200 copay per visit for hospital based services.
Out-of-network
20% of the cost
Primary Care Provider Visit
In-network
$0 PCP copay per visit
Out-of-network
20% of the cost
Specialist Visit
In-network: $25 copay per visit
Out-of-network: 20% of the cost
Referral is required for specialist visits.
Vision Visit
Routine vision
In-network: $0
Out-of-network: 20% of the cost
Non-routine vision
In-network: $25 copay per visit
Out-of-network: 20% of the cost
Vision hardware
Our plan offers a $200/year allowance for vision hardware.
Hearing Services
Routine hearing
In-network: $0
Out-of-network: 20% of the cost
Non-routine hearing
In-network: $25 copay per visit
Out-of-network: 20% of the cost
Hearing aids
$0-$1,475 copay per hearing aid (2 aids every year)
Preventive Care
In-network: $0
Out-of-network: 20% of the cost
Inpatient Hospital Care
In-network: $225 copay per day for days 1-5, $0 Days 6+
Out-of-network: 20% of the cost
Skilled Nursing Facility (SNF)
In-network
$0 copay per day for days 1-20
$214 copay per day for days 21-45
$0 copay per day for days 46-100
Out-of-network
20% of the cost
Our plan covers up to 100 days in a SNF
No deductible
Tier 1 (Preferred Generic)
$3 copay
Tier 2 (Non-preferred Generic)
$6 copay
Tier 3 (Preferred Brand)
$47 copay
Tier 4 (Non-preferred Drug)
$100 copay
Tier 5 (Specialty Tier)
33% of the cost
Mail Order (100-day Supply)
$0 copay for Tiers 1 and 2
Insulins (30-day Supply)
$35
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 Enhanced (HMO-POS), BlueCHiP for Medicare Extra (HMO-POS), BlueCHiP for Medicare Preferred (HMO-POS), or the BlueCHiP for Medicare Access (HMO-POS) plan. If you select the BlueCHiP for Medicare Value, BlueCHiP for Medicare Enhanced (HMO-POS), BlueCHiP for Medicare Extra, BlueCHiP for Medicare Preferred, 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.
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 Initial Coverage stage and the Catastrophic level stage.