BlueMedicare Complete (HMO D-SNP) 2024

$0 copay

$0 copay

$0 copay

$0 copay

$0 copay in and out-of-network

$0 or up to $480.
Applies to Tiers 3,4,5 only

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

Tier 4 - Non-Preferred Drugs*

Preferred Retail (31-day supply): $92
Standard Retail (31 day supply): $99
Preferred Retail (90 day supply): $276
Standard Retail (90 day supply): $297
Mail Order (90 day supply): $276

Tier 5 - Specialty Drugs*

All Locations (31-day supply): 25% of the costs

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 network retail pharmacy. You pay no more than $0 for Tier 2 medications at a network retail 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 Vision
Routine Hearing
SilverSneakers Fitness Program
Routine Transportation
Over-the-Counter Items Allowance
Meals after hospital discharge
Telehealth Services
At Home Care
Health Education
Caregiver 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.