FHCP Medicare Rx Savings (HMO)
Health Insurance Company: Florida Blue HMO
Medicare Advantage Plan Details
- Rx
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
$100 copay per visit (always covered)
Ambulance Coverage
$300 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $0-300 copay
Medicare-covered lab services: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): $10-200 copay
Medicare-covered x-ray services: $10-50 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: $0-400 copay per visit
Hospitalization Coverage
Inpatient hospital-acute:
$500 per day for days 1 through 4
$0 per day for days 5 through 90
$0 per day for days 91 and beyond
Inpatient hospital psychiatric:
$465 per day for days 1 through 4
$0 per day for days 5 through 90
$0 per day for days 91 and beyond
Rehabilitation Coverage
Occupational therapy services:
$20 copay
Physical therapy and speech and language therapy services:
$0-20 copay
Urgent Care Coverage
$20-45 copay per visit (always covered)
Skilled Nursing Facility (SNF)
$0 per day for days 1 through 20
$172 per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: $40 copay
Medicare-covered group sessions: $40 copay
Dental, Vision, Hearing Benefits
Vision Benefits
Eye exams:
Routine eye exams: $15 copay
Eyewear:
Contact Lenses: Not covered
Eyeglasses: $0 copay
Hearing Benefits
Hearing exams:
Routine hearing exams: $45 copay
Hearing aids:
Hearing aids (all types): $0 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$10.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 3: Preferred Brand
$45.00 copay (30-day supply)
$135.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$17.00 copay (30-day supply)
$51.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
More Additional Benefits
Plan Links
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