Premera Blue Cross Medicare Advantage Total Health (HMO)

Health Insurance Company: Premera Blue Cross Medicare Advantage

Medicare Advantage Plan Details

Premera Blue Cross Medicare Advantage
$23 /mo
monthly premium
Premera Blue Cross Medicare Advantage Total Health (HMO)
Additional Coverage
Overall Star Rating (2024)
  • Rx
  • Dental
  • Vision
  • Hearing
3
out of 5 stars

General Plan Details

Medical Deductible
$0
Out-of-Pocket Maximum
$5000
Rx Drug Coverage
Yes
Rx Deductible
$0
Primary Doctor Office Visit
$0 copay
Specialist Office Visit
$30 copay per visit

Additional Benefits

Dental Coverage
Yes
Vision Coverage
Yes
Mental Health Coverage
Yes
Transportation for non-emergency
No
Fitness Benefits
Yes
Worldwide emergency
Yes
Telehealth
Yes
Part B Give Back
No

Doctor & Hospital Coverage

Primary Doctor Office Visit
$0 copay
Specialist Office Visit
$30 copay per visit
Periodic Exam Coverage
$0 copay

Emergency Room

$90 copay per visit (always covered)

Ambulance Coverage

$275 copay

Lab, X-Ray, Radiology Coverage

Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $30 copay
Medicare-covered lab services: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): $160 copay
Medicare-covered x-ray services: $10 copay

Outpatient Surgery Coverage

Outpatient hospital:
Medicare-covered outpatient hospital services: $275 copay per visit

Hospitalization Coverage

Inpatient hospital-acute:
$350 per day for days 1 through 4
$0 per day for days 5 through 90
Inpatient hospital psychiatric:
$390 per day for days 1 through 4
$0 per day for days 5 through 90

Rehabilitation Coverage

Occupational therapy services:
$10 copay
Physical therapy and speech and language therapy services:
$10 copay

Urgent Care Coverage

$35 copay per visit (always covered)

Skilled Nursing Facility (SNF)

$0 per day for days 1 through 20
$160 per day for days 21 through 60
$0 per day for days 61 through 100

Mental Health Coverage

Medicare-covered individual sessions: $30 copay
Medicare-covered group sessions: $30 copay

Dental, Vision, Hearing Benefits

Dental Services

Oral exams: $0 copay
Prophylaxis (cleaning): $0 copay
Dental x-rays: $0 copay

Vision Benefits

Eye exams:
Routine eye exams: $0 copay
Eyewear:
Contact Lenses: $0 copay
Eyeglasses: $0 copay

Hearing Benefits

Hearing exams:
Routine hearing exams: $30 copay
Hearing aids:
Hearing aids (all types): $0 copay

Rx Drug Coverage - Standard Retail Cost

Tier 1: Preferred Generic

$2.00 copay (30-day supply)
$6.00 copay (90-day supply)

Tier 2: Generic

$10.00 copay (30-day supply)
$30.00 copay (90-day supply)

Tier 3: Preferred Brand

$40.00 copay (30-day supply)
$120.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

33% coinsurance (30-day supply)

Tier 1: Preferred Generic

$2.00 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

$40.00 copay (30-day supply)
$120.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

33% coinsurance (30-day supply)

More Additional Benefits

Annual physical exams
Yes
Chiropractic Coverage
Yes
Acupuncture
Yes
Massage Therapy
No
Health Education
No
Counseling Services
No
Support for Caregivers of Enrollees
No
Personal Emergency Response System (PERS)
No
In-home support services
No
Home and bathroom safety devices
No
Meals for short duration
No

Plan Links

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Where This Plan is Available

State:
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Additional Plan Info

Plan Year:
2024
Insurance Company Website:
Premera Blue Cross Medicare Advantage

Health Insurance Companies Offering Plans

Medicare Advantage and Part D plans and benefits offered by the following carriers:

  • Aetna Medicare
  • Anthem Blue Cross Blue Shield
  • Aspire Health Plan
  • Dean Health Plan
  • Devoted Health
  • GlobalHealth
  • Health Care Service Corporation
  • Cigna Healthcare
  • Humana
  • Medica Central Health Plan
  • Molina Healthcare
  • Mutual of Omaha
  • Premera Blue Cross
  • SCAN Health Plan
  • Scott and White Health Plan now part of Baylor Scott & White Health
  • UnitedHealthcareⓇ
  • Wellcare