Understand Plan Features
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 |
$4,900 for Medicare-covered services |
| Inpatient Care |
Days 1-5: $300 copay per day |
| Outpatient Surgery |
$300 copay per visit |
|
Diagnostic Procedures, Tests, and Lab Services |
$10 copay per day for labs and other diagnostic tests; $250 copay per day for certain high-tech imaging; $0 copay for therapeutic radiological services |
|
X-rays |
$10 copay per day |
|
Emergency Care |
$90 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 every 12 months 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 or exercise class fees 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, 2 and 6 | $0 |
| Tiers 3, 4 |
$320 |
|
Initial Coverage |
Preferred Cost-Sharing Pharmacies |
Standard Cost-Sharing Pharmacies |
Express Scripts Mail Service |
|---|---|---|---|
|
Tier 1: Preferred Generic |
$2 copay |
$8 copay |
$2 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 |
N/A |
| Tier 6: Select Care | $0 copay | $5 copay | N/A |
| Coverage Gap |
After your total yearly drug costs reach $4,130, 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 $6,550 you pay the greater of:
|
||
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
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Other Medicare Plans
- 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.