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BlueMedicare Value Choice (PPO)

Plan costs

Premium $29.00 monthly

Benefits

Medical Coverage
Medical Deductible$0.00
Doctor Office Visits$0 co-pay per Primary Care visit.
Specialist Office Visit$40 co-pay per visit.
Telehealth$0 co-pay for Urgently Needed Services, Primary Care Physician Services, Individual or Group Sessions for Mental Health Specialty Services, Individual or Group Sessions for Psychiatric Services.
$20 co-pay for Physician Specialist Services.
Inpatient Hospital Care$375 co-pay per day for days 1-5, $0 co-pay per day for days 6-90.
BlueMedicare SapphireOur new Blue Medicare Sapphire benefit is a $500 prepaid debit card to help pay for dental, vision and hearing out-of-pocket costs. See the Summary of Benefits to learn more.
Healthy Blue RewardsYou take care of your health, and we take care of you. When you complete certain healthcare-related activities, we’ll send you gift card rewards. You can earn up to $250 in rewards in 2022.
Comprehensive dental benefitsYou get comprehensive dental benefits that go far beyond the standard dental benfits covered by Original Medicare. See the Summary of Benefits to learn more.
Comprehensive hearing benefitsYou’ll receive expanded hearing benefits in addition to the standard hearing benefits covered by Original Medicare. See the Summary of Benefits to learn more.
Comprehensive vision benefitsYou’ll also get expanded vision benfits in addition to the standard vision benefis covered by Original Medicare. See the Summary of Benfits to learn more.
Over-the-Counter Items$25 allowance per quarter without rollover.
Meal BenefitUp to 14 nutritious meals (two meals per day for seven days) per year following discharge from the hospital.
24/7 Nurse HotlinePlan members get access to the Nurse24 nurse line, which gives you access to a registered nurse 24 hours a day, 7 days a week, 365 days a year. Nurses can provide information on home treatment of minor illnesses and injuries, how to prepare for doctor visits, understanding your prescription drugs, and much more.
SilverSneakers® fitness programThe plan offers members access to a basic fitness program at no additional cost. The benefit is administered through a plan-authorized vendor with contracted facilities. If a member is unable to access a facility, they may receive a fitness kit delivered in the mail.
In-Network Maximum Out Of Pocket$6,000.00
Medical Coverage (Out-of-Network)
Combined In and Out of Network Maximum Out of Pocket$11,300.00
Doctor Office Visits$25 co-pay per Primary Care visit.
Specialist Office Visit40% coinsurance per visit.
Inpatient Hospital Care40% coinsurance per admission of per stay.
Pharmacy Coverage
Prescription Deductible$150.00
Pharmacy Deductible Drug Tier Exclusions$0 Deductible on Tier(s) 1, 2, 3, 6; $150 Deductible on Tier(s) 4, 5
Initial Coverage Limit$4,430.00
One-Month Supply (Retail Pharmacy) with Standard Cost Sharing
Preferred Generic$3.00
Generic$13.00
Preferred Brand$47.00
Non-Preferred Drug$100.00
Specialty Tier30%
Select Care Drugs$0.00
Part D Senior Savings ModelReceive select insulins at a stable, predictable co-pay of $0 for a 30- and 100-day supply.
100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing
Preferred Generic$0.00
Generic$0.00
Preferred Brand$141.00
Non-Preferred Drug$300.00
Specialty TierNot covered
Select Care Drugs$0.00
Plan Documents
Summary of Benefits2022 HMO Summary of Benefits[pdf]
Plan DocumentsPlan Documents

Preferences

Plan: H3554-003

Limitations, copayments, and restrictions may apply. See above or contact the plan for more details.

*Enrollee must continue to pay the Medicare Part B premium.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. 24 hours a day, 7 days a week.
  • The Social Security Office at 800-772-1213. TTY users should call 1-800-325-0778. Monday through Friday, 7 a.m. to 7 p.m.
  • Your State Medicaid Office.