Empire MediBlue Choice (HMO-POS)

Empire MediBlue Choice (HMO-POS) H8432-015 Plan Details
3 out of 5 stars

Empire MediBlue Choice (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Empire BlueCross BlueShield.
Plan ID: H8432-015.

$105.00
Monthly Premium

Empire MediBlue Choice (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Empire BlueCross BlueShield.
Plan ID: H8432-015.

Empire MediBlue Choice (HMO-POS) H8432-015 Plan Details
3 out of 5 stars

Empire MediBlue Choice (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Empire BlueCross BlueShield.
Plan ID: H8432-015.

$105.00
Monthly Premium

New York Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $350
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:
$15.00 copay
Out-of-Network:
40% coinsurance
Specialty Doctor Visit
In-Network:
$50.00 copay
Out-of-Network:
40% coinsurance
Inpatient Hospital Care
In-Network:
Days 1-4: $450.00 per day, per admission / Days 5-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
40% coinsurance per stay
Urgent Care
Urgent Care: $65.00 copay
Emergency Room Visit
Emergency Care: $90.00 copay
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance Transportation
Ground Ambulance: $300.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Empire MediBlue Choice (HMO-POS) 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:
Medicare Covered Chiropractic Services: $20.00 copay
Out-of-Network:
Medicare Covered Chiropractic Services: 40% coinsurance
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Out-of-Network:
30% coinsurance
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Out-of-Network:
30% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $55.00 - $85.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 - $150.00 copay
Diagnostic Radiological Services: $100.00 - $250.00 copay
Out-of-Network:
Lab Services: 40% coinsurance
X-Rays: 40% coinsurance
Therapeutic Radiological Services: 40% coinsurance
Outpatient Diagnostic Procedures/Tests: 40% coinsurance
Diagnostic Radiological Services: 40% coinsurance
Home Health Care
In-Network:
$0.00 copay
Out-of-Network:
40% coinsurance
Mental Health Inpatient Care
In-Network:
Days 1-4: $450.00 per day, per admission / Days 5-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
40% coinsurance per stay
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $40.00 copay
Out-of-Network:
40% coinsurance
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: 30% coinsurance
Observation Services: 30% coinsurance
Ambulatory Surgical Center: 30% coinsurance
Out-of-Network:
Outpatient Hospital - Surgery: 40% coinsurance
Observation Services: 40% coinsurance
Ambulatory Surgical Center: 40% coinsurance
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $40.00 copay
Out-of-Network:
40% coinsurance
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $50.00 copay
Out-of-Network:
Medicare Covered Podiatry Services: 40% coinsurance
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $188.00 per day
Out-of-Network:
40% coinsurance per stay

Dental Benefits

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

Coverage Cost
Dental Care
Medicare Covered Dental: $0.00 copay
Out-of-Network:
Medicare Covered Dental Services: 40% coinsurance

Vision Benefits

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

Coverage Cost
Vision Benefits
In-Network:
Medicare Covered Eye Exam: $0.00 - $50.00 copay
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: $0.00 copay
Out-of-Network:
Medicare Covered Eye Exam: 40% coinsurance
Medicare Covered Eye Wear: 40% coinsurance

Hearing Benefits

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

Coverage Cost
Hearing Benefits
In-Network:
Medicare Covered Hearing Exam: $50.00 copay
Out-of-Network:
Medicare Covered Hearing Exam: 40% coinsurance

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
Out-of-Network:
40% coinsurance

Prescription Drug Costs and Coverage

The Empire MediBlue Choice (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $350 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $350 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Preferred retail $15.00
  • Standard retail $20.00
  • Standard mail order $15.00
Annual Drug Deductible $350 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Preferred retail $30.00
  • Standard retail $40.00
  • Standard mail order $45.00
Annual Drug Deductible $350 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Preferred retail $45.00
  • Standard retail $60.00
  • Standard mail order $45.00