BlueMedicare Premier (HMO) 2025

$0 copay

$0 copay

$0 copay

$95 copay; ER copay waived if admitted

$0 copay in and out-of-network

$0

Tier 1 - Preferred Generics

Preferred Retail (31-day supply): $0 copay
Standard Retail (31-day supply): $10 copay
Preferred Retail (90-day supply): $0 copay
Standard Retail (90-day supply): $30 copay
Mail Order (90-day supply): $0 copay

Tier 2 - Generics

Preferred Retail (31-day supply: $0 copay
Standard Retail (31-day supply): $11 copay
Preferred Retail (90-day supply): $0 copay
Standard Retail (90-day supply): $33 copay
Mail Order (90-day supply): $0 copay

Tier 3 - Preferred Brands

Preferred Retail (31-day supply): $0 copay
Standard Retail (31-day supply): $12 copay
Preferred Retail (90-day supply): $0 copay
Standard Retail (90-day supply): $36 copay
Mail Order (90-day supply): $0 copay

Tier 4 - Non-Preferred Drugs

Preferred Retail (31-day supply): $50 copay
Standard Retail (31-day supply): $75 copay
Preferred Retail (90-day supply): $150 copay
Standard Retail (90-day supply): $225 copay
Mail Order (90-day supply): $150 copay

Tier 5 - Specialty Drugs

All Locations (31-day supply): 33% of the costs

This plan has a $6,000 Initial Coverage Limit. Once your total drug costs (what you and any part D plan pays) reach $6,000, you will move to the coverage gap. The standard Initial Coverage Limit is $4,130 for 2022 plans. Our higher Initial Coverage limit means it will take longer for you to reach the coverage gap.

This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 2 (generics)medications are covered in the coverage gap. For these tiers, you continue to pay the same cost-sharing amounts as in the Initial Coverage Stage. You pay no more than $0 for Tier 1 medications at a preferred pharmacy. You pay no more than $0 for Tier 2 medications at a preferred pharmacy. You will pay no more than 25% of the costs for generics in all other tiers. For all brand drugs you pay no more than 25% of the costs.

You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs.

Routine Dental
Routine Hearing
Routine Vision
SilverSneakers Fitness Program
Routine Transportation
Over-the-Counter Items Allowance
Telehealth Services
At Home Care
Caregiver Support
Health Education

If you receive care from an out-of network provider without prior authorization from our plan, the care will not be covered except for emergency care, urgently needed care and dialysis services.

We generally cover drugs filled at an out-of-network pharmacy only if you are not able to use one of our network pharmacies (for example, because you are traveling, need emergency or urgent care, or need a drug that it not available at an accessible network pharmacy). Chapter 5 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy.