BLUE ADVANTAGE HMO

With Blue Advantage, you don’t need to buy a separate Medicare supplement or Part D prescription drug plan.

Even better, the plan comes with the valuable extra benefits such as dental, vision, hearing and fitness coverage that helps save you even more. And with the Silver & Fit® Program, you can get a no-cost fitness facility membership with access to a broad network of participating fitness facilities nationwide or the Home Fitness option, plus rewards, challenges and much more.

Covered Benefit

Member Share

Plan Year Deductible

$0

Out-of-Pocket-Maximum (In-Network)

$2,000

Out-of-Pocket Maximum (Out-of-Network)

There is no out-of-pocket maximum.

Co-pay – Primary Care/Specialist

$5/$20 per visit (In network)

Emergency Room

$50 co-pay per visit

Inpatient Hospital

$50/day (days 1-10 in network)

Prescription Drugs (Part D)

 
  •  Tier 1
  •  Tier 2
  •  Tier 3
  •  Tier 4
  •  Tier 5
  •  $5
  •  $10
  •  $25
  •  $50
  •  20%
You may view the formulary at www.bcbsla.com/blueadvantage

Additional Benefits

Preventative Dental

$0 copay for preventative visits.

Comprehensive Dental

50% coinsurance limited to $1,000 per year for basic services.

Routine Hearing Exam

One hearing exam per year; up to $500 reimbursement allowance for hearing aids per year.

Eyewear

$130 allowance for one pair of eye glasses or contact lenses per year.