BlueSaver (HMO)
BlueSaver (HMO) H3384-062 Plan Details
BlueSaver (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3384-062
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
BlueSaver (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3384-062
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
New York Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $250 |
| Out of Pocket Max |
In-Network: $6900 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $360.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Maximum out of Pocket $1800.00 every year Prior Authorization Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $55.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $55.00 |
| Emergency Room Visit | Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $295.00 Air Ambulance: Copayment for Air Ambulance Services $295.00 Prior authorization required for air/water ambulance. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
BlueSaver (HMO) 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 $15.00 Copayment for Routine Care $15.00
|
| 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 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment 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 $50.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $175.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $45.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $395.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Maximum out of Pocket $1580.00 every year Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $375.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $375.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $275.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $25.00 every three months |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30.00 Copayment for Routine Foot Care $30.00
|
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Preventive Dental: Copayment for Office Visit: $0 including: • Oral Exams Maximum 2 per year • Prophylaxis (Cleaning) Maximum 2 per year • Fluoride Maximum 2 per year • Dental X-Rays Maximum 1 visit every year Medicare Covered Dental Services: Copayment for Medicare-covered Benefits $30.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 50% Maximum Plan Benefit of $2000.00 every year combined for Preventive and Non-Medicare Covered Comprehensive services |
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 $30.00 Copayment for Routine Eye Exams $25.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $100.00 every year for all Non-Medicare covered eyewear |
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 $30.00 Copayment for Routine Hearing Exams $45.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
|
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 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:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The BlueSaver (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $250 (excludes Tiers 1, 2 and 3) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $250 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Annual Drug Deductible | $250 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Annual Drug Deductible | $250 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
