BluePathway Plan 1 H6936-006-0 (HMO) Plan Details

Arizona Counties Served

Maricopa County

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%