BluePathway Plan 1 H6936-006-0 (HMO) Plan Details
- Learn more about HumanaChoice R7220-002 (Regional PPO) R7220:002-0 Plan Details, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan.
Arizona Counties Served
Plan Details and Plan Costs
BluePathway Plan 1 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered in Arizona by BluePathway. The plan ID is H6936:006-0.
- Monthly Premium: $0
- Plan Deductible: $0.00
- Out of Pocket Spending Max: $2900
Primary Care Doctor Visit
In Network: Copayment for Primary Care Office Visit $0.00
Specialist Doctor Visit
In Network:
- $20 Copayment for Physician Specialist Office Visit
- Prior Authorization Required for Doctor Specialty Visit
- Referral Required for Doctor Specialty Visit
Inpatient Hospital Care
In Network:
- $175.00 per day for days 1 to 5
- $0.00 per day for days 6 to 90
- Maximum out of Pocket $875.00
- Prior Authorization Required for Acute Hospital Services
Urgent Care
Copayment for Urgent Care $20.
Emergency Room (ER) Visits
In Network:
- Copayment for Emergency Care: $120.00
- Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours.
Ambulance Transportation
In Network:
- Ground Ambulance: $250 copayment
- Air Ambulance: 20% coinsurance
- No authorization is required for emergency ambulance transport.
- Water Ambulance services - 20% coinsurance.
- Copayment or coinsurance will be assessed for each segment of ambulance transport.
- Please see Evidence of Coverage for Prior Authorization rules
Additional Covered Health Care Services and Medical Supplies
BluePathway Plan 1 (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
Home Health Care
In Network: $0.00 Copay
- Prior Authorization Required for Home Health Services
Skilled Nursing Facility (SNF) Care
In Network:
- $0.00 per day for days 1 to 20
- $184.00 per day for days 21 to 40
- $0.00 per day for days 41 to 100
- Prior Authorization Required for Skilled Nursing Facility Services
Medical Diagnostic Tests, Labs and Radiology Services
Outpatient Diagnostic Procedures, Tests and Lab Services:
- Copayment for Medicare-covered Diagnostic Procedures/Tests: $0.00 to $75.00
- Copayment for Medicare-covered Lab Services: $0.00 to $50
- Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
- Referral Required for Outpatient Diag Procs/Tests/Lab Services
Outpatient Diagnostic and Therapeutic Radiology Services:
- Copayment for Medicare-covered Diagnostic Radiological Services: $0 to $200
- Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
- Coinsurance for Medicare-covered Therapeutic Radiological Services: 20%
- Copayment for Medicare-covered X-Ray Services $0.00
- Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
- Referral Required for Outpatient Diag/Therapeutic Rad Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
- Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
- Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts: 20%
- Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable Medical Equipment (DME)
In Network:
- Coinsurance for Medicare-covered Durable Medical Equipment 20%
- Prior Authorization Required for Durable Medical Equipment
- This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Chiropractic Services
In Network:
- Copayment for Medicare-covered Chiropractic Services: $20.00
- Prior Authorization Required for Chiropractic Services
- Copayment for Routine Care $30.00
- Maximum 20 Routine Care every year
- Prior Authorization Required for Chiropractic Services
- Referral Required for Chiropractic Services
- Chiropractor Services benefit combined with either the Acupuncture or Alternative Therapies benefit. Please see Evidence of Coverage
Mental Health Inpatient Care
In Network:
- $175.00 per day for days 1 to 5
- $0.00 per day for days 6 to 90
- Prior Authorization Required for Psychiatric Hospital Services
Mental Health Outpatient Care
In Network:
- Copayment for Medicare-covered Individual Sessions: $20
- Copayment for Medicare-covered Group Sessions: $20
Outpatient Substance Abuse Care
In Network:
- Copayment for Medicare-covered Individual Sessions $20.00
- Copayment for Medicare-covered Group Sessions $20.00
Podiatry Services
In Network:
- Copayment for Medicare-Covered Podiatry Services: $20.00
- Referral Required for Podiatry Services
- Prior Authorization Required for Podiatry Services
Over-the-Counter (OTC) Items
Copayment for Over-The-Counter (OTC) Items: $0.00
- Maximum Plan Benefit of $50.00 every three months
Dental Benefits
The following dental services are covered from in-network providers.
Preventive Dental Care
Covered Benefits:
- Oral Exams: Copayment for Oral Exams $0.00
- Maximum 2 visits every year
- Teeth Cleaning: Copayment for Prophylaxis (Cleaning) $0.00
- Maximum 2 visits every year
- Dental X-Rays: Copayment for Dental X-Rays $0.00
- Maximum 2 visits every year
- Maximum Plan Benefit: Maximum Plan Benefit of $1000.00 every year
Comprehensive Dental Care
Medicare-Covered Benefits:
- Coinsurance for Medicare-covered Benefits 20%
- Prior Authorization Required for Comprehensive Dental
- Referral Required for Comprehensive Dental
Vision Benefits
The following vision services are covered from in-network providers.
Eye Exams
Medicare-Covered Benefits:
- Copayment for Medicare Covered Benefits: $0.00 to $20
Routine Eye Exams:
- Copayment for Routine Eye Exams: $0.00
- Maximum 1 Routine Eye Exam every year
- Prior Authorization Required for Eye Exams
- Referral Required for Eye Exams
Eyewear
Coinsurance for Medicare-Covered Benefits 20%
- Contact Lenses: Copayment for Contact Lenses $0.00
- Eyeglasses (lenses and frames): Copayment for Eyeglasses (lenses and frames) $0.00
- Maximum Plan Benefit: Maximum Plan Benefit of $200.00 every two years for all Non-Medicare covered eyewear
- Prior Authorization Required for Eyewear
- Referral Required for Eyewear
Hearing Benefits
The following vision services are covered from in-network providers.
Hearing Exams
Medicare-Covered Benefits:
- Copayment for Medicare Covered Benefits: $20.00
- Routine Hearing Exams: Copayment for Routine Hearing Exams $0.00
- Maximum 1 visit per year
- Prior Authorization Required for Hearing Exams
- Copayment for Fitting/Evaluation for Hearing Aid $0.00 (1 per year)
Hearing Aids
- Copayment for Hearing Aids $699.00 to $999.00
- Maximum 2 Hearing Aids every year
- Prior Authorization Required for Hearing Aids
- Referral Required for Hearing Aids
- Maximum Plan Benefit: $699 copayment per ear per year for advanced level hearing aid purchase or $999 copayment per ear per year for premium level hearing aid purchase.
- Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearing's Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options for no additional cost. You must see a TruHearing provider to use this benefit.
Hearing aid purchase includes:
- 3 provider visits within first year of hearing aid purchase
- 45-day trial period
- 3-year extended warranty
- 48 batteries per aid for non-rechargeable models
Benefit does not include or cover any of the following:
- Ear molds
- Hearing aid accessories
- Additional provider visits
- Additional batteries, batteries when a rechargeable hearing aid is purchased
- Hearing aids that are not TruHearing-branded hearing aids
- Costs associated with loss & damage warranty claims
Preventive Services and Health/Wellness Education Programs
The following preventive services and wellness education programs are covered from in-network providers with $0.00 Copayment.
- Abdominal aortic aneurysm screening
- Alcohol misuse screenings & counseling
- Bone mass measurements (bone density)
- Cardiovascular disease screenings
- Cardiovascular disease (behavioral therapy)
- Cervical & vaginal cancer screening
- Colorectal cancer screenings
- Depression screenings
- Diabetes screenings
- Diabetes self-management training
- Glaucoma tests
- Hepatitis B (HBV) infection screening
- Hepatitis C screening test
- HIV screening
- Lung cancer screening
- Mammograms (screening)
- Nutrition therapy services
- Obesity screenings & counseling
- One-time Welcome to Medicare preventive visit
- Prostate cancer screenings(PSA)
- Sexually transmitted infections screening & counseling
Shots:
- Flu shots
- Hepatitis B shots
- Pneumococcal shots
Prescription Drug Costs and Coverage
The BluePathway Plan 1 (HMO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $0.00 per year.
Preferred Generic Drugs
- Standard Retail Cost Sharing (30 Day Supply) $0.00
- Standard Mail Order Cost Sharing (90 Day Supply) $0.00
Generic Drugs
- Standard Retail Cost Sharing (30 Day Supply) $7.00
- Standard Mail Order Cost Sharing (90 Day Supply) $7.00
Preferred Brand Name Drugs
- Standard Retail Cost Sharing (30 Day Supply) $40.00
- Standard Mail Order Cost Sharing (90 Day Supply) $120.00
Non-Preferred Drugs
- Standard Retail Cost Sharing (30 Day Supply) $90.00
- Standard Mail Order Cost Sharing (90 Day Supply) $270.00
Specialty Tier Drugs
- Standard Retail Cost Sharing (30 Day Supply) 33%


