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Medicare HMO Blue PlusRx (HMO)

$167* per month Overall Plan Rating Star Rating Enroll Now Call us:
1-800-678-2265
TTY:
1-800-522-1254

Hours of operation:
7 days a week
8 a.m. - 8 p.m.
Or have us call you.
Request a Call

Benefits at a Glance

Medicare HMO BlueSM PlusRx

Monthly Plan Premium

$167*

Plan Information

Medical

Doctor Office Visits

$15 copay per visit

Specialist Office Visits

$30 copay per visit

Medicare Preventive Services

$0 copay per visit

Annual Medical Out-of-Pocket Maximum

$3,400

Inpatient Care

Days 1–5: $150 copay per day
$750 annual out-of-pocket maximum

Outpatient Hospital Care / Surgery

$150 copay per visit

Diagnostic Procedures, Tests and Lab Services

$0 copay for lab; $100 copay per day for certain high-tech imaging, and $0 copay for X-rays and other diagnostic tests

Emergency Care

$65 copay per visit

Other Preventive Services

Preventive Dental

$30 copay per visit

Annual Routine Vision Exam

$30 copay for 1 routine test per year

Eyeglasses Benefit

$150 limit for routine eyewear every 2 years

Annual Routine Hearing Exam

$15–$30 copay for 1 routine test per year

Hearing Aid Benefit

Up to $400 limit every 3 years

Annual Fitness Benefit

Up to $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 for Tiers 1 and 2; $120 for Tiers 3, 4 and 5

Initial Coverage

30-day retail

90-day mail order

Tier 1: Preferred Generic

$4 copay

$4 copay

Tier 2: Non-Preferred Generic

$8 copay

$16 copay

Tier 3: Preferred Brand

$45 copay

$90 copay

Tier 4: Non-Preferred Brand

$95 copay

$190 copay

Tier 5: Specialty Drugs

30% of the cost

30% of the cost

Coverage Gap

After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. For covered generics, you pay 72% 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

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:
$2.55 copay for generics or brand drugs treated like generic drugs
$6.35 copay for all other drugs; or 5% of the cost

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

  • Coverage for routine hearing exams and vision care

  • Allowances toward hearing aids and eyewear

  • Routine preventive dental care

  • Prevention and wellness programs

  • Worldwide coverage for emergency care

Summary of Benefits and Evidence of Coverage

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