Medicare HMO Blue ValueRx (HMO)

Download 2013 Summary of Benefits

Benefits at a Glance

	Medicare HMO Blue^SM ValueRx
Monthly Plan Premium	$28.00¹
Plan Information
*Medical*
Doctor Office Visits	$0—$20 copay
Specialist Office Visits	$0—$40 copay
Medicare Preventive Services	$0 copay
Annual Medical Out-of-Pocket Maximum	$3,400
Inpatient Care	Days 1—5: $250 copay per day $1,250 annual out-of-pocket maximum²
Outpatient Hospital Care / Surgery	$0—$200 copay²
Diagnostic Procedures, Tests and Lab Services	$20 copay per day for lab; $150 copay per day for certain high-tech imaging, and $0 copay for X-rays and other diagnostic tests²
Emergency Care	$0—$65 copay
*Other Preventive Services*
Annual Routine Vision Exam	$40 copay for 1 routine test per year
Eyeglasses Benefit	$150 limit for eyewear every 2 years
Annual Routine Hearing Exam	$20—$40 copay for 1 routine test per year
Hearing Aid Benefit	Not covered
Annual Fitness Benefit	$150 toward fitness club membership per year
Weight Loss Benefit	Up to $150 toward fees paid for qualified Weight Watchers^®'' or hospital-based weight loss programs
*Prescription Drug Coverage*	Cost
Annual Deductible	$0 Tiers 1 and 2; $220 Tiers 3, 4 and 5
Initial Coverage	30-day retail	90-day mail order
Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Drugs	$6 copay $12 copay $45 copay $90 copay 27% of the cost	$6 copay $24 copay $90 copay $180 copay 27% of the cost
Coverage Gap	For covered generics, you pay 79% of the plan's costs. For covered brand drugs, you pay no more than 47.5% of the plan's costs (excluding dispensing fees)
Catastrophic Coverage	You pay the greater of: $2.65 copay for generics or drugs treated like generic drugs $6.60 copay for brands 5% of the cost

1. Your monthly premium will be different if you qualify for Extra Help from Medicare.

2. After you pay your $1,000 annual deductible.

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
Routine preventive dental care
Prevention and wellness programs
Worldwide coverage for emergency care

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

Medicare HMO Blue ValueRx (HMO)

Benefits at a Glance

Summary of Benefits and Evidence of Coverage