Empire MediBlue Select (HMO)

Empire MediBlue Select (HMO) H8432-027 Plan Details
3 out of 5 stars

Empire MediBlue Select (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Empire BlueCross BlueShield.
Plan ID: H8432-027.

$0.00
Monthly Premium

Empire MediBlue Select (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Empire BlueCross BlueShield.
Plan ID: H8432-027.

Empire MediBlue Select (HMO) H8432-027 Plan Details
3 out of 5 stars

Empire MediBlue Select (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Empire BlueCross BlueShield.
Plan ID: H8432-027.

$0.00
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:
$20.00 copay
Specialty Doctor Visit
In-Network:
$50.00 copay
Inpatient Hospital Care
In-Network:
Days 1-5: $400.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
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: $285.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Empire MediBlue Select (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:
Medicare Covered Chiropractic Services: $20.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $25.00 - $75.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 - $50.00 copay
Diagnostic Radiological Services: $75.00 - $125.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days 1-5: $370.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $40.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $400.00 copay
Observation Services: $400.00 copay
Ambulatory Surgical Center: $400.00 copay
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $40.00 copay
Over-the-counter (OTC) Items
This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $27 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $50.00 copay
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $188.00 per day

Dental Benefits

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

Coverage Cost
Dental Care
Medicare Covered Dental: $0.00 copay

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
Routine Eye Wear: $0.00 copay
This plan covers up to $100.00 for eyeglasses or contact lenses every year.

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

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

Prescription Drug Costs and Coverage

The Empire MediBlue Select (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $350 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $350 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $3.00
  • Standard retail $8.00
  • Standard mail order $3.00
Generic
  • Preferred retail $15.00
  • Standard retail $20.00
  • Standard mail order $15.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $350 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $6.00
  • Standard retail $16.00
  • Standard mail order $9.00
Generic
  • Preferred retail $30.00
  • Standard retail $40.00
  • Standard mail order $45.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $350 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $9.00
  • Standard retail $24.00
  • Standard mail order $9.00
Generic
  • Preferred retail $45.00
  • Standard retail $60.00
  • Standard mail order $45.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00