Medical Coverage
| Benefit | You Pay: |
|---|---|
|
Annual Deductible
The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay. |
$0 |
|
Maximum Out Of Pocket
The most you pay for copays, coinsurance and other costs for medical services for the year. |
$6,700 |
|
PCP Office Visits
Your Primary Care Provider (PCP) is the provider you see first for most health problems. They make sure you get the care you need to keep you healthy. |
$0 copay |
|
Specialist Office Visits
A specialist is a doctor who practices one type of medicine. (For example, a cardiologist is a specialist in heart and cardiovascular issues.) Your Primary Care Provider (PCP) may talk with a specialist about your care, or refer you to one if needed. |
$0 copay |
|
Inpatient Hospital Facility Services
Inpatient care is provided in a hospital after you've been admitted. An overnight stay is not automatically considered inpatient care. |
0% coinsurance |
|
Dental Services
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. |
Cleaning(s): $0 copay
|
|
Ambulance
Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health or if authorized by the plan. |
0% coinsurance |
|
Chiropractic Services
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position). |
0% coinsurance for 20 routine visits per year |
|
Diabetes Self-Monitoring Training, Nutrition Therapy, and supplies
For all people who have diabetes (insulin and non-insulin users). |
$0 copay |
|
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
Copay may vary depending on place of service. |
Advanced imaging services (such as MRIs, CT scans): 0% coinsurance
|
|
Durable Medical Equipment
Certain medical equipment, like a walker, wheelchair, or hospital bed, that's ordered by your doctor for use in the home. |
0% coinsurance |
|
Emergency Services (In and out-of-network)
Emergency services are the care and services you get for a sudden illness or injury that isn't life threatening but that requires medical treatment right away. If it's not safe to wait until you can get home to see a doctor in your Medicare plan network, the plan pays for your care. |
0% coinsurance |
|
Hearing Services
Medicare covered and routine hearing exams, hearing aids. |
$2,500 allowance for a routine hearing exam, hearing aid fitting/evaluation, and hearing aid, combined.
|
|
Home Health Care
Health care services and supplies a doctor decides you may get in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor. |
$0 copay |
|
Dialysis
ESRD/ Kidney Dialysis |
0% coinsurance |
|
Meals
Meal service for a set amount of time after a qualified acute inpatient hospital stay or skilled nursing facility stay. |
Up to 2 meals for up to 7 days after an Inpatient Hospital stay1
|
|
Outpatient Surgery
Surgical care you get from a hospital when your doctor hasn't written an order to admit you to the hospital as an inpatient. |
Outpatient hospital: 0% coinsurance
|
|
Rehabilitation and Therapy Services
Treatment of an injury or a disease by mechanical means, like exercise, massage, heat, and light treatment. |
Covered¹ |
|
Personal Emergency Response System (PERS)
The personal emergency response system provides help in emergency situations. The medical alert service comes with an installed in-home communication device and a wearable button. |
Covered¹
|
|
Preventive Services
Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms). |
$0 copay |
|
Prosthetic Devices
Devices such as braces, artificial limbs, and ostomy supplies. |
0% coinsurance |
|
Fitness Benefit
SilverSneakers® Fitness, a premier exercise program designed just for you, is available to our members at 14,000+ fitness locations across the state and throughout the country, including national chains, local gyms, and women-only sites. |
SilverSneakers membership included at no cost |
|
Skilled Nursing Facility (SNF)
A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services. |
0% coinsurance per day for days 1 through 100
|
|
Urgent Care Facility
Urgent Care Facilities treat non-life-threatening injuries or illnesses that require medical treatment right away. For example, if you cut your finger and need stitches, you should go to Urgent Care. |
0% coinsurance |
|
Transportation
One-way trips for covered health services. |
Up to 100 one-way trips |
|
Over-the-Counter (OTC) Benefit
Products include, but are not limited to, vitamins, cough, cold and allergy medicine, dental products, blood pressure monitors and skin care items. |
$300 quarterly allowance |
|
Vision Services
Medicare covered and routine vision exams plus coverage for eyewear. |
Routine exam (for up to 1 per year): $0 copay
|
Prescription Drug Coverage
| Benefit | You Pay: |
|---|---|
|
Deductible (applies to all drugs)
The amount you must pay before our Plan begins to pay its share of your covered drugs. Example: If a drug plan has a $350.00 deductible you must pay the first $350.00 of covered drug expenses before the plan begins to pay its portion of your cost. |
$0.00 |
|
Tier 1 - Preferred Generics
These generic drugs (prescription drugs that have the same active ingredients as brand-name drugs) typically have the lowest cost to the customer of all drugs for the diagnosis. |
$0 - $3.40
|
|
Tier 2 - Generics
Prescription drugs that have the same active ingredients as brand-name drugs. Generic drugs usually cost less than brand-name drugs, and are deemed just as safe and effective by the Food and Drug Administration (FDA). |
$0 - $3.40
|
|
Tier 3 - Preferred Brands
These brand-name drugs are covered by your plan. There may be a less expensive generic version of these drugs available. |
$0 - $8.50
|
|
Tier 4 - Non Preferred Brands
These drugs are covered by our plan, but you may pay more for them. |
$0 - $3.40
|
|
Tier 5 - Specialty Drugs
Specialty drugs are typically high cost, self-administered drugs that require considerable support to manage and administer. These drugs often treat rare, chronic conditions and may require unique delivery or dispensing considerations. Additional patient support, safety monitoring, compliance and patient training may be required to manage these conditions. |
$0 - $3.40
|
|
Coverage in the Coverage Gap
After your out-of-pocket costs, plus the amount of the drug manufacturer's discounts, reach $5,100 |
There is no coverage gap. Once you leave the Initial Coverage Stage, you move on to the Catastrophic Coverage Stage. |
Extra Coverage
| Benefit | |
|---|---|
|
Extra Benefits
Free benefits included in this plan |
Routine Preventive and Comprehensive Dental
|
Out of Network Coverage
| Benefit | |
|---|---|
|
Medical Services/Supplies
Medical Services/Supplies |
It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which BlueCare Plus (HMO SNP) authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) of the Evidence of Coverage (EOC) for more specific information about emergency, out-of-network, and out-of-area coverage. |
|
Prescription Drugs
Prescription Drugs |
You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable or inaccessible and it is not reasonable to wait to obtain care from your network provider when the network becomes available, we will cover urgently needed services that you get from an out-of-network provider. Generally, if you cannot use a network provider during a disaster, your plan will allow you to obtain care from out-of-network providers at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of –network pharmacy. Please see Chapter 5, Section 2.5 of the Evidence of Coverage (EOC) for more information.
|
Plan Documents
| Summary of Benefits (PDF) | |
| Evidence of Coverage | |
| Plan Rating | |
| General Transition Notice (PDF) | |
| Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) | |
| Annual Notice of Change | |
| Find a Doctor, Hospital, and Pharmacy |
Value Added Benefits
Member Account
BlueAccess Member Portal - Access your health care information here. Online access is an easy way to get up-to-date information about your plan.
Fitness membership at no additional cost
A fitness program designed just for you, is available to our members at locations across the state and throughout the country, including national chains, and local gyms!
Member Perks
BlueCross members can save money on health and wellness products and services with Blue365® – our discount program. Get weekly emails filled with new discounts on leading national brands and be sure to check the local deals in your area!