BlueMedicare Choice (Regional PPO)

BlueMedicare Choice (Regional PPO) R3332-001 Plan Details
3.5 out of 5 stars

BlueMedicare Choice (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: R3332-001.

$51.90
Monthly Premium

BlueMedicare Choice (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: R3332-001.

BlueMedicare Choice (Regional PPO) R3332-001 Plan Details
3.5 out of 5 stars

BlueMedicare Choice (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: R3332-001.

$51.90
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $250
Out of Pocket Max In-Network: $6500
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $10.00

Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit DED + 50%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $50.00

Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit DED + 50%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$345.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services

Out-of-Network:
DED + $495.00 per day for days 1 to 27
$0.00 per day for days 28 to 90
Prior authorization required
Urgent Care
Copayment for Urgent Care $50.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $125.00
Maximum Plan Benefit of $25,000
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 48 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125.00
Maximum Plan Benefit of $25,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $225.00

Air Ambulance:
Copayment for Air Ambulance Services $225.00

Except for emergency care, prior authorization is required for ambulance services, in-network only. Contact Member Services for more information.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Copayment for Medicare Covered Ambulance Services - Air $250.00

Health Care Services and Medical Supplies

BlueMedicare Choice (Regional PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00

Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services DED + 50%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00

Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services DED + 0%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment

Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment DED + 50%
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $50.00
Copayment for Medicare-covered Lab Services $0.00 to $40.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $40.00 to $150.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $50.00 to $150.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests DED +
50%
Coinsurance for Medicare Covered Lab Services DED + 50%
Coinsurance for Medicare Covered Diagnostic Radiological Services DED + 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services DED + 50%
Coinsurance for Medicare Covered Outpatient X-Ray Services DED + 50%
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services

Out-of-Network:
Coinsurance for Medicare Covered Home Health DED + 50%
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$318.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services

Out-of-Network:
DED + $495.00 per day for days 1 to 27
$0.00 per day for days 28 to 90
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $20.00 to $150.00
Copayment for Medicare Covered Group Sessions $20.00 to $150.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $150.00
Coinsurance for Medicare Covered Outpatient Hospital Services 20%

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $90.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $120.00
Prior Authorization Required for Ambulatory Surgical Center Services

Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services DED + 50%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services DED + 50%
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00 to $150.00
Copayment for Medicare-covered Group Sessions $20.00 to $150.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $20.00 to $150.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $40.00

Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services DED + 50%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$160.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Out-of-Network:
DED + $250.00 per day for days 1 to 58
$0.00 per day for days 59 to 100
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $50.00
Prior Authorization Required for Comprehensive Dental

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental DED + 50%
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $50.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00

Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams DED + 50%
Coinsurance for Medicare Covered Eyewear DED + 50%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams DED + 50%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $50.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $350.00 every year per ear for in and out of network services combined
Hearing aids must be purchased through NationsHearing to receive in-network benefits.
Member is responsible for any amount after the benefit allowance has been applied.

Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams DED + 50%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams DED + 50%
Coinsurance for Non-Medicare Covered Hearing Aids DED + 50%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

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
Diabetic Prevention Program
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Health and wellness education programs
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:
  • COVID-19 shots
Flu shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit


Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

Prescription Drug Costs and Coverage

The BlueMedicare Choice (Regional PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $250 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $250 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $10.00
  • Standard mail order $0.00
Generic
  • Preferred retail $10.00
  • Standard retail $20.00
  • Standard mail order $10.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $250 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail N/A
  • Standard retail N/A
  • Standard mail order N/A
Generic
  • Preferred retail N/A
  • Standard retail N/A
  • Standard mail order N/A
Select Care Drugs
  • Preferred retail N/A
  • Standard retail N/A
  • Standard mail order N/A
Annual Drug Deductible $250 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $30.00
  • Standard mail order $0.00
Generic
  • Preferred retail $30.00
  • Standard retail $60.00
  • Standard mail order $30.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00