BlueMedicare Value (PPO) 2024

Level 1 $0 Copayment in-network
Level 2 (All Other) $10 Copayment in-network

Level 1 $35 Copayment in-network
Level 2 (All Other) $48 Copayment in-network

$275 copay per day for days 1-6 in-network

$90 copay; ER copay waived if admitted

$30 copay in and out-of-network

$150 (applies to Tiers 3, 4, 5)

Tier 1 - Preferred Generics

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

Tier 2 - Generics

Standard Retail (31-day supply): $8 copay
Standard Retail (90-day supply): $24 copay
Mail Order (90-day supply): $24 copay

Tier 3 - Preferred Brands

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

Tier 4 - Non-Preferred Drugs

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

Tier 5 - Specialty Drugs

All Locations (31-day supply): 30% of the costs

Tier 6 - Select Care Drugs

All Locations (31-day supply): $0 copay
All Locations (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 network retail pharmacy. You pay no more than $0 for Tier 6 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
Telehealth Services
At Home Care
Caregiver Support
Over-the-Counter
Health Education

If you receive care from an out-of-network provider, your out-of-pocket costs will usually be higher than if you use a network provider. There are three exceptions: emergency care, urgently needed care and dialysis services. For details about the plan's coverage of out-of-network care, please refer to the Summary of Benefits or the Evidence of Coverage. (See "Plan Documents" below.)

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.