BlueElite Plan F

  Original Medicare BlueElite
Plan F
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Plan Name  Original Medicare Plan F
Plan Type Original Medicare Medicare Supplement
Monthly Premium N/A View BlueElite Monthly Premiums PDF
Inpatient Mental Health Care $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Skilled Nursing Facility You pay for each benefit period:
$0 per day for days 1-20
$144.50 for days 21-100
$0 per day for days 1-100
Home Health Care $0 copay per visit $0 copay per visit
Hospice Medicare Pays: 100% for hospice care. All but $5 for prescription drugs. 95% for inpatient respite care $0
Chiropractic Services $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Podiatry Services $140 Part B Deductible; 20% of Medicare-approved amounts $140 Part B Deductible; Plan pays Medicare coinsurance
Durable Medical Equipment $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Prosthetic Devices $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Outpatient Mental Health Caree $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Outpatient Substance Abuse Care $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Ambulance Services $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Emergency Care $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Urgently Needed Care $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Outpatient Rehabilitation Services $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Diabetes Self-Monitoring Training, Nutrition Therapy and Supplies $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Diagnostic Tests $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Advanced Imaging $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Therapeutic Radiology $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Cardiac/Pulmonary Rehab $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Abdominal Aortic Aneurysm Screening $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Bone Mass Measurement You will pay nothing for covered preventive services if you get the services from a doctor or other health care provider who accepts Medicare assignment. $0 for Medicare covered Preventive Services.
Colorectal Screening Exams You will pay nothing for covered preventive services if you get the services from a doctor or other health care provider who accepts Medicare assignment. $0 for Medicare covered Preventive Services.
Immunizations/vaccines You will pay nothing for covered preventive services if you get the services from a doctor or other health care provider who accepts Medicare assignment. $0 for Medicare covered Preventive Services.
Mammograms (Annual Screenings) You will pay nothing for covered preventive services if you get the services from a doctor or other health care provider who accepts Medicare assignment. $0 for Medicare covered Preventive Services.
Pap Smears and Pelvic Exams You will pay nothing for covered preventive services if you get the services from a doctor or other health care provider who accepts Medicare assignment. $0 for Medicare covered Preventive Services.
Prostate Cancer Screening Exams You will pay nothing for covered preventive services if you get the services from a doctor or other health care provider who accepts Medicare assignment. $0 for Medicare covered Preventive Services.
Dialysis (kidney) $140 Part B Deductible; 20% of Medicare-approved amounts $0 per visit; Plan pays Medicare coinsurance plus excess charges
Annual Physical Exam You will pay nothing for covered preventive services if you get the services from a doctor or other health care provider who accepts Medicare assignment. $0 for Medicare covered annual wellness exam.
Hearing Services $140 Part B Deductible; 20% of Medicare-approved amounts; Routine not covered $0 per visit; Plan pays Medicare coinsurance plus excess charges; Routine not covered
Vision Care $140 Part B Deductible; 20% of Medicare-approved amounts for diagnosis and treatment of diseases and conditions of the eye; Routine not covered $0 per visit; Plan pays Medicare coinsurance plus excess charges. Routine not covered. $0 for one pair of eyeglasses or contact lenses following cataract surgery.
Retail Pharmacy
To the right are the prices for a 30-day supply of a drug in the tiers listed.
Not covered Not covered
BluePerks Discount Drug CardPDF
Mail Pharmacy
To the right are the prices for a 90-day supply of a drug in the tiers listed.
Not covered Not covered
BluePerks Discount Drug CardPDF
Health Education and Wellness N/A BluePerks PDF
Health Management
Downloads Choosing A Medigap Policy PDF Choosing A Medigap Policy PDF
Member Handbook PDF (Coming Soon)
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