BlueMedicare Value (PPO) 2025

$0 copay in-network

Level 1 $35 Copayment in-network
Level 2 (All Other) $44 Copayment in-network

$295 copay per day for days 1-6 in-network

$120 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 (100-day supply):$0 copay
Mail Order (100-day supply): $0 copay

Tier 2 - Generics

Standard Retail (31-day supply): $4 copay
Standard Retail (100-day supply): $12 copay
Mail Order (100-day supply): $12 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 (100-day supply): $0 copay

This plan has coverage in the Part D coverage gap. 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 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.

$0 copay

Routine Dental
Routine Vision
Routine Hearing
SilverSneakers Fitness Program
Telehealth Services
Caregiver Support
Over- the-Counter

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.