Overview
Deductible
Medical
In-network services: $280 Point of service: $500
Pharmacy
Most generic drugs: $0 All other covered drugs: $200
Out-of-pocket maximum
$4,500
Optional supplemental benefits and care received through our point-of-service benefit don't count toward your out-of-pocket maximum.
Office visits
Primary care physician
You pay $0 after deductible.
Specialist
You pay $45 after deductible.
Urgent care
Pharmacy
Copays start at $0 for certain generic drugs filled at a preferred network pharmacy.
You'll need to meet your $200 pharmacy deductible for drugs on tiers 2-5. Some drugs may cost more if you choose a pharmacy in our standard network.
Find your pharmacy.
Drug list
You get more than Original Medicare
All benefits required by Original Medicare and more, including:
• Blue Cross Online VisitsSM
• Two dental exams and cleanings and one vision exam each year
• Coverage while traveling outside of Michigan with the BlueCard® program (PDF).
• SilverSneakers® fitness program
• MyBlueSM Concierge program
Medical
Doctor and hospital choice
This is an HMO-POS plan. HMO stands for health maintenance organization. It's a group of health care professionals that provide services to members. You choose a primary care physician from your network who coordinates all your care and refers you to specialists. In most cases, we don’t cover care you get outside our network except in an emergency.
POS stands for point of service. It means you can get care from doctors outside of Michigan under certain conditions. Find a doctor in this plan's network.
Preventive services
Includes services such as:
• Welcome to Medicare exam
• Personalized prevention plan services
• Bone mass measurement
• Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
• Immunizations (including flu, pneumonia and Hepatitis B vaccines)
• Screening mammograms
• Pap smears
• Behavioral counseling to reduce alcohol misuse
• Behavioral therapy for cardiovascular disease and obesity
You pay $0
Doctor office visits
Primary care physician: You pay a $0 copay after deductible.
Specialist: You pay a $45 copay after deductible.
Blue Cross Online Visits
Medical: You pay a $0 copay after deductible.
Behavioral health: You pay a $40 copay after deductible.
Outpatient surgery
Ambulatory surgical center: You pay a $100 copay after deductible.
Hospital: You pay a $225 copay after deductible.
Doctor's office: You pay a $50 copay after deductible.
Inpatient hospital care
Days 1-6: You pay a $285 copay per day after deductible.
Days 7-90: You pay $0 after deductible.
Skilled nursing facility
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
Days 1-20: You pay $0 after deductible.
Days 21-100: You pay a $178 copay per day after deductible.
Urgent care
Emergency care
Worldwide urgent care
You pay a $45 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
Worldwide emergency care
You pay a $90 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
Durable medical equipment
You pay 20% of the cost after deductible.
Durable medical equipment must be received through a Northwood Inc. provider.
Ambulance services
You pay a $230 copay after deductible.
Chiropractic services
Spinal manipulation: You pay a $20 copay after deductible.
Annual exam: You pay a $45 copay after deductible.
Annual X-ray: You pay a $20 copay after deductible.
Podiatry services
You pay a $45 copay after deductible.
Outpatient behavioral health services
Includes individual and group therapy visits.
You pay a $40 copay after deductible.
Occupational, physical and speech therapy
You pay a $30 copay after deductible.
Renal dialysis
You pay 20% of the cost after deductible.
Prescriptions
Pharmacy deductible
This plan has a $200 pharmacy deductible for Tiers 2-5. You pay full price for drugs before you meet the deductible, except for Tiers 1 and 6, which have no deductible. You can save by going to a preferred pharmacy in our network. Check out the example of what you'll pay for a one-month supply at a preferred pharmacy compared with a standard pharmacy.
Initial coverage: Before costs reach $4,020
Tier 1: Preferred generic drugs
Commonly prescribed generic versions of brand medications. You’ll pay the least for these drugs at the pharmacy.
Preferred pharmacy: You pay $3.
Standard pharmacy: You pay $9.
Tier 2: Generic drugs
Although you’ll pay more at the pharmacy for these generic drugs, they're more cost-effective than brand medications.
Preferred pharmacy: You pay $11 after deductible.
Standard pharmacy: You pay $20 after deductible.
Tier 3: Preferred brand drugs
Brand drugs that aren’t available yet as a generic.
Preferred pharmacy: You pay $42 after deductible.
Standard pharmacy: You pay $47 after deductible.
Tier 4: Nonpreferred drugs
Because there are alternatives for the drugs in this tier, you’ll pay more for them at the pharmacy.
Preferred pharmacy: You pay 50% of the cost after deductible.
Standard pharmacy: You pay 50% of the cost after deductible.
Tier 5: Specialty drugs
Specialty drugs are used to treat complex conditions like cancer and multiple sclerosis. Although they can be generic or brand, they usually need special handling and approval. You may have to order them through a specialty pharmacy.
Preferred pharmacy: You pay 29% of the cost after deductible.
Standard pharmacy: You pay 29% of the cost after deductible.
Tier 6: Select care drugs
Select care drugs are generic drugs used to treat diabetes and high cholesterol.
Preferred pharmacy: You pay $0.
Standard pharmacy: You pay $5.
Coverage gap: When costs are $4,020 - $6,350
Tier 6 generic drugs: $0 at a preferred pharmacy, $5 at a standard pharmacy
All other drugs: You pay 25% of the cost.
Catastrophic coverage: When costs are more than $6,350
Generic drugs: You pay a $3.60 copay or 5% of the cost, whichever is greater.
Other drugs: You pay an $8.95 copay or 5% of the cost, whichever is greater.
Dental, Vision, Hearing
Dental
This plan covers these preventive services for $0 copay in network:
• Two oral exams every year
• Two routine cleanings every year
• Up to four bitewing x-rays or up to six periapical films every other calendar year
• Original Medicare covered dental care services are covered with a copay of $0-$225 depending on place of service.
What's not covered:
• Dental procedures like fillings, crowns, root canals and simple extractions
• Fluoride treatments
Add more dental, vision and hearing coverage for an additional cost.
Vision
You can choose from any provider from the VSP Choice network.
This plan covers these benefits for $0 copay:
• One routine eye exam every year
• A diabetic retinopathy exam
• One pair of Medicare-covered glasses or contact lenses after cataract surgery.
This plan also covers:
• Medicare-covered exam for a $45 copay.
What's not covered:
• Glasses or contact lenses
• LASIK or RK (radial keratotomy) surgery
Add more dental, vision and hearing coverage for an additional cost.
Hearing
You pay:
• $0 to $45 for Medicare-covered diagnostic only hearing exams. These are tests your doctor orders for you to see if you need medical treatment. Your primary care physician or specialist copay applies.
What's not covered:
• Routine hearing exams
• Hearing aids or exams for fitting hearing aids
Add more dental, vision and hearing coverage for an additional cost.
Documents
Learn more about this plan
Find a doctor or pharmacy
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