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Plan Information

Medical

Doctor Visits

$10 copay per office or telehealth visit

Specialist Visits

$40 copay per office or telehealth visit

Medicare Preventive Services

$0 copay per visit

Annual Medical Out-of-Pocket Maximum

$3,450 for Medicare-covered services
Inpatient Care

Days 1-5: $330 copay per day
Outpatient Surgery

$250 copay per visit

Diagnostic Procedures, Tests, and Lab Services

$10 copay per day for labs and other diagnostic tests; $250 copay per day per category of test for certain high-tech imaging; $0 copay for therapeutic radiological services

X-rays

$10 copay per day

Emergency Care

$105 copay per visit
Other Preventive Services

Preventive Dental

$0 copay per visit, twice each calendar year

Annual Routine Vision Exam

$0 copay for one routine exam every 12 months with an EyeMed vision provider

Eyeglasses Benefit

$200 limit for routine eyewear every 24 months from an EyeMed vision provider

Annual Physical Exam

$0 copay

Annual Routine Hearing Exam

$0 copay for one routine exam per year with a TruHearing provider

Hearing Aid Benefit

$699 or $999 copayment per TruHearing hearing aid (one per ear per year)

Annual Fitness Benefit

Up to $150 toward fitness club membership, exercise class fees, online class fees, and fitness equipment per year

Weight Loss Benefit

Up to $150 toward fees paid for qualified weight loss programs per year

To confirm your eligibility and schedule a routine vision or hearing appointment please contact:

EyeMed: 1-866-490-7291 (TTY: 711)

October 1 through March 31: 8:00 a.m. - 11:00 p.m. ET., 7 days a week
April 1 through September 30: 8:00 a.m. - 11:00 p.m. ET., Monday through Saturday; 11:00 a.m. - 8:00 p.m, Sunday.

TruHearing: 1-844-811-3762 (TTY: 711)

8:00 a.m. - 9:00 p.m. ET, Monday through Friday.

Prescription Drug Coverage

Prescription Drug Annual Deductible 

 Cost
Tiers 1 and 2 $0
Tiers 3, 4, and 5

$320

Initial Coverage 

Preferred Cost-Sharing Pharmacies
Amount for 30-day supply

Standard Cost-Sharing Pharmacies
Amount for 30-day supply

Express Scripts Mail Service
Amount for 90-day supply

Tier 1: Preferred Generic

$0 copay

$8 copay

$0 copay

Tier 2: Generic

$6 copay

$12 copay

$12 copay

Tier 3: Preferred Brand

$42 copay

$47 copay

$84 copay

Tier 4: Non-Preferred Brand

$95 copay

$100 copay

$190 copay

Tier 5: Specialty Drugs

27% of the cost

27% of the cost

not available at 90-day supply
Coverage Gap 

After your total yearly drug costs reach $4,430, you receive limited coverage by the plan on certain drugs. For covered generics, you pay 25% of the plan's costs. For covered brand drugs, you pay no more than 25% of the plan's costs (excluding dispensing fees).
Catastrophic Coverage 

After your yearly out-of-pocket drug costs reach $7,050 you pay the greater of:

  • $3.95 copay for generics or drugs treated like generic drugs and a $9.85 copay for all other drugs; or
  • 5% of the cost

Additional Benefits

As a Medicare HMO Blue ValueRx plan member, you get additional benefits beyond Original Medicare, such as:

  • Coverage for routine hearing exams and vision care
  • Allowances toward eyewear and hearing aids
  • Routine preventive dental care
  • Prevention and wellness programs
  • Worldwide coverage for emergency care

Prescription Drug Coverage

Medicare HMO Blue ValueRx also offers Medicare Part D prescription drug coverage—making it easy for you to get your medical and prescription benefits from one plan.

Summary of Benefits and Evidence of Coverage

  • Your monthly premium will be different if you qualify for Extra Help from Medicare.
  • This information is not a complete description of benefits. Call 1-800-200-4255 (TTY: 711) for more information.
  • Every year, Medicare evaluates plans based on a 5-star rating system.