BlueMedicare Classic Plus (HMO) 2024

$0 copay

$35 copay

$205 Copay Per Day 1-6

$90 copay; ER copay waived if admitted

$40 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): $10 copay
Standard Retail (31-day supply): $15 copay
Preferred Retail (90-day supply): $30 copay
Standard Retail (90-day supply): $45 copay
Mail Order (90-day supply): $30 copay

Tier 3 - Preferred Brands

Preferred Retail (31-day supply): $40 copay
Standard Retail (31-day supply): $47 copay
Preferred Retail (90-day supply): $120 copay
Standard Retail (90-day supply): $141 copay
Mail Order (90-day supply): $120 copay

Tier 4 - Non-Preferred Drugs

Preferred Retail (31-day supply): $93 copay
Standard Retail (31-day supply): $100 copay
Preferred Retail (90-day supply): $279 copay
Standard Retail (90-day supply): $300 copay
Mail Order (90-day supply): $279 copay

Tier 5 - Specialty Drugs

All Locations (31-day supply) : 33% of the costs
Tier 6- Select Care Drugs
Preferred Retail (31-day supply): $0 copay
Standard Retail (31-day supply): $0 copay
Preferred Retail (90-day supply): $0 copay
Standard Retail (90-day supply): $0 copay
Mail Order (90-day supply): $0 copay

This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 6 (select care) 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 6 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.

Routine Dental
Routine Hearing
Routine Vision
SilverSneakers Fitness Program
Telehealth Services
At Home Care
Over- the-Counter
Health Education
Caregive support

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.