BlueMedicare Classic (HMO)
Plan costs
Premium $0.00 monthly
Benefits
| 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 Rewards | As 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. |
| 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. |
| Over-the-Counter Items | Not covered |
| 24/7 Nurse Hotline | Access 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 program | Access 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 | $6,000.00 |
| Medical Coverage (Out-of-Network) | |
|---|---|
| Out-of-network coverage | Out-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 Exclusions | Tier 1, Tier 2, and Tier 6 |
| Initial Coverage Limit | $4,660.00 |
| One-Month Supply (Retail Pharmacy) with Standard Cost Sharing | |
| Preferred Generic | $3 copay |
| Generic | $13 copay |
| Preferred Brand | $40 copay |
| Non-Preferred Drug | 31% coinsurance |
| Specialty Tier | 29% coinsurance |
| Select Care Drugs | $0 copay |
| Part D Senior Savings Model | Not covered |
| 100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing | |
| Preferred Generic | $6 copay |
| Generic | $26 copay |
| Preferred Brand | $80 copay |
| Non-Preferred Drug | 31% coinsurance |
| Specialty Tier | Not covered |
| Select Care Drugs | $0 copay |
| Plan Documents | |
|---|---|
| Summary of Benefits | 2023 Health Advantage HMO Summary of Benefits [pdf] |
| Plan Documents | Plan Documents |
Preferences
Plan: H9699-004-002
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.