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BlueMedicare Classic (HMO)

Plan costs

Premium $0.00 monthly


Medical Coverage
Medical Deductible$0.00
Doctor Office Visits$0 copay
Specialist Office Visit$40 copay
Telehealth$0 copay for urgently needed services, primary care provider services, and outpatient mental health (mental health specialty and psychiatry - individual and group sessions).
$40 copay for specialist services.
Inpatient Hospital Care$365 copay per day for days 1-5.
$0 copay per day for days 6-90.
$0 copay per day for days 91 and beyond.
Healthy Blue RewardsAs a Health Advantage member, you’ll be eligible to earn valuable rewards for getting exams, preventive screenings, tests and completing other health-related activities.
In-Home Support Services$0 copay for 40 hours per year.
Get in-person or virtual help with making medical appointments, transportation, chores, meal prep, companionship, etc. Plus, no prerequisite to access services.
Blue Medicare Sapphire card$300 pre-loaded Mastercard debit card to help reduce out-of-pocket expenses for covered dental, vision, and hearing services.
Comprehensive dental benefits$2,000 per year for comprehensive (and preventive) dental services. Please see plan documents for more details.
Comprehensive hearing benefits$0 copay for 1 routine hearing exam per year.
$699/$999 copay per hearing aid (2 per year).
Please see plan documents for more details.
Comprehensive vision benefits$0 copay for 1 routine eye exam per year.
$100 per year for routine eyewear (contacts, eyeglasses, and upgrades).
Please see plan documents for more details.
Over-the-Counter ItemsNot covered
24/7 Nurse HotlineAccess to the Nurse24 nurse advice line 24 hours a day, 7 days a week, 365 days a year. Registered nurses can provide information on home treatment of minor illnesses and injuries, how to prepare for doctor visits, how to understand your prescription drugs, and much more.
SilverSneakers® fitness programAccess to a fitness benefit virtually and at participating SilverSneakers facilities, giving you access to instructor-led group exercise classes, exercise equipment, and options to get active outside of traditional gyms, as well as virtual options.
In-Network Maximum Out Of Pocket$5,000.00
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 on Tier 3, Tier 4, and Tier 5
Pharmacy Deductible Drug Tier ExclusionsTier 1, Tier 2, and Tier 6
Initial Coverage Limit$4,660.00
Preferred Generic$3 copay
Generic$13 copay
Preferred Brand$40 copay
Non-Preferred Drug31% coinsurance
Specialty Tier29% coinsurance
Select Care Drugs$0 copay
Part D Senior Savings ModelNot covered
100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing
Preferred Generic$6 copay
Generic$26 copay
Preferred Brand$80 copay
Non-Preferred Drug31% coinsurance
Specialty TierNot covered
Select Care Drugs$0 copay
Plan Documents
Summary of Benefits2023 Health Advantage HMO Summary of Benefits [pdf]
Plan DocumentsPlan Documents


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.