$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 | $45 Copay | ||
| Urgent Care | $40 Copay | ||
| Emergency Room Care | $90 Copay | ||
| Inpatient Hospital Care | $175 Per Day for Days 1-10; $0 Per Day for Days 11-90 (per admit) | ||
| Outpatient Hospital Surgery | $275 Copay | ||
| Maximum Out-of-Pocket Limit | $5,500 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.
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