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Health Advantage Blue Classic (HMO)

Plan costs

Premium $0.00 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.
$40 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.
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.
In-Home Support ServicesPapa, Inc. will provide up to 40 hours per year at no cost for help scheduling/attending medical visits, transportation to your physician/pharmacy, telehealth support, light housekeeping, chores, and meal prep.
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 benefitsNot covered.
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)
Out-of-network coverageOut-of-network services are not covered, except for emergency and urgently needed care. You must use network providers for plan services, except in emergency situations.
Pharmacy Coverage
Prescription Deductible$250.00
Pharmacy Deductible Drug Tier Exclusions$0 Deductible on Tier(s) 1, 2, 6; $250 Deductible on Tier(s) 3, 4, 5
Initial Coverage Limit$4,430.00
Preferred Generic$3.00
Generic$13.00
Preferred Brand$40.00
Non-Preferred Drug45%
Specialty Tier28%
Select Care Drugs$0.00
100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing
Preferred Generic$6.00
Generic$26.00
Preferred Brand$80.00
Non-Preferred Drug45%
Specialty TierNot covered
Select Care Drugs$0.00
Plan Documents
Summary of Benefits2022 Health Advantage HMO Summary of Benefits[pdf]
Plan DocumentsPlan Documents

Preferences

Plan: H9699-004-001

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.