Coverage Summary
Is My Doctor In-Network?
Benefit: | You Pay: |
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Primary Care Doctor Visit | $0 copay |
Specialist Visit | $10 copay |
Inpatient Hospital Care | $125 copay per day for days 1-6 |
Emergency Services (In and out-of-network) | $115 copay; ER copay waived if admitted |
Urgent Care Services | $10 copay in and out-of-network |
Prescription Drug Coverage
Benefit: | You Pay: |
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Prescription Drug Deductible | $0 |
In-Network Prescription Drug Coverage - Initial Coverage | Tier 1 - Preferred Generics |
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. |
Catastrophic Coverage | 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. |
Extra Coverage
Benefit: | |
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Extra Benefits | Routine Dental |
Out of Network Coverage
Benefit: | |
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Medical Services/Supplies | 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. |
Prescription Drugs | 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. |
Plan Documents
Summary of Benefits (PDF) |
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Evidence of Coverage (PDF) |
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Plan Rating (PDF) |
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General Transition Notice (PDF) |
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Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) |
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Comprehensive Formulary (PDF) |
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Service Area Map | |
Annual Notice of Change |
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Enrollment Forms |
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Why Choose Florida Blue Medicare?
Online Member Portal
A secure members only website that keeps you in control of your health and wellness with a variety of easy-to-use tools.
Fitness Program
SilverSneakers gives you unlimited access to over 14,000 gyms and wellness programs. Enjoy services like fitness classes, treadmills, weights, pools and more at no extra cost to you.
Case Management Coordination of Care
A dedicated consultant to assist with coordinating appointments, in or outpatient stays, management of chronic conditions and help with finding the best price on procedures and prescriptions.
Florida Blue Centers/FHCP Centers
Enjoy face-to-face customer service, wellness events and educational seminars at one of our unique retail centers.
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