BlueMedicare Premier (HMO) 2025

$0 copay

$15 copay

$150 copay per day for days 1-7

$120 copay; ER copay waived if admitted

$10 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): $2 copay
Standard Retail (31-day supply): $15 copay
Preferred Retail (90-day supply): $6 copay
Standard Retail (90-day supply): $45 copay
Mail Order (90-day supply): $6 copay

Tier 3 - Preferred Brands

Preferred Retail (31-day supply): $30 copay
Standard Retail (31-day supply): $47 copay
Preferred Retail (90-day supply): $90 copay
Standard Retail (90-day supply): $141 copay
Mail Order (90-day supply): $90 copay

Tier 4 - Non-Preferred Drugs

Preferred Retail (31-day supply): $90 copay
Standard Retail (31-day supply): $100 copay
Preferred Retail (90-day supply): $270 copay
Standard Retail (90-day supply): $300 copay
Mail Order (90-day supply): $270 copay

Tier 5 - Specialty Drugs

All Locations (31-day supply): 33% 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 preferred pharmacy. You pay no more than $2 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 Vision
Routine Hearing
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.