$0 premium
$925 Mastercard® Flex Card to pay for out-of-pocket expenses
$0 deductible for in-network medical services
$0 in-network primary care visits, including online visits with BlueCare
$0 deductible for prescription drugs
$0 copay for a three-month supply of Tier 1 drugs at a preferred retail pharmacy or by mail order
See a specialist without a referral
Dental, vision, hearing, fitness center membership, over-the-counter supplies
With an HMO plan, you must use network providers to get your medical care and services (except in limited situations)
In-Network Medical |
|||
|---|---|---|---|
| HMO | |||
| Premium | $0 Per Month | ||
| Medical Deductible | $0 Per Year | ||
| Preventive Care | $0 Copay | ||
| Primary Care Visits | $0 Copay | ||
| Specialist Visits | $40 Copay | ||
| Urgent Care | $40 Copay | ||
| Emergency Room Care | $90 Copay | ||
| Inpatient Hospital Care | $125 Per Day for Days 1-10; $0 Per Day for Days 11-90 (per admit) | ||
| Outpatient Hospital Surgery | $200 Copay | ||
| Maximum Out-of-Pocket Limit | $6,700 Per Year | ||
Blue Advantage (HMO) Prescription Drug Benefits* |
|||
|---|---|---|---|
| Deductible | $0 prescription drug deductible | ||
| Preferred Retail and Mail-Order Cost-Sharing | |||
| Tier | One-Month Supply | Two-Month Supply | Three-Month Supply |
| Tier 1 (Preferred Generics) | $3 copay | $6 copay | $0 copay |
| Tier 2 (Generics) | $12 copay | $24 copay | $36 copay |
| Tier 3 (Preferred Brand) | $45 copay | $90 copay | $135 copay |
| Tier 4 (Non-Preferred Drug) | $100 copay | $200 copay | $300 copay |
| Tier 5 (Specialty) | 33% coinsurance | Not Offered | Not Offered |
| Standard Retail and Mail-Order Cost-Sharing | |||
| Tier | One-Month Supply | Two-Month Supply | Three-Month Supply |
| Tier 1 (Preferred Generics) | $10 copay | $20 copay | $30 copay |
| Tier 2 (Generics) | $18 copay | $36 copay | $54 copay |
| Tier 3 (Preferred Brand) | $47 copay | $94 copay | $141 copay |
| Tier 4 (Non-Preferred Drug) | $100 copay | $200 copay | $300 copay |
| Tier 5 (Specialty) | 33% coinsurance | Not Offered | Not Offered |
*For in-network pharmacies only
Plan Features to Help Keep You Healthy |
|
|---|---|
| Flex Card | $925 Mastercard® Flex Card to help pay for out-of-pocket costs, including:
|
| Dental Services | Preventive and basic dental services at no cost, including two dental cleanings and two exams per year ($1,200 total allowance) |
| Vision Services | No-cost routine eye exam (up to 1 every year) with the freedom to choose from hundreds of participating providers and retailers, plus $225 to spend on eyewear via Flex Card |
| Hearing Services | $10 copay for routine hearing exam (up to 1 every year), plus $500 to spend on prescription hearing aids via Flex Card |
| Fitness Benefit | No-cost fitness center membership or home fitness kits |
| Over-the-Counter Supplies | $200 ($50 per quarter) via Flex Card to spend at major retailers or to order online or by phone for home delivery |
| Online Primary Care | $0 copay for 24/7 online medical visits through BlueCare |
| Member Wellness Rewards | Up to $50 per year in gift cards from major retailers for completing approved wellness exams and/or screenings |
| 24-hour Nurse Help Line | Talk to a registered nurse at any time to help make the right choice in care based on symptoms |
* For in-network services only, where applicable. Retailer restrictions may apply.
The Silver&Fit Program is provided by American Specialty Health Fitness Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a registered trademark of ASH and used with permission herein. All programs and services are not available in all areas.
Click below to search for Hospitals or Medical Providers in the Vantage Network.
