Managed Blue for Seniors Benefits at a Glance
Benefit Your cost
Preventive care Nothing
Routine office visits $10 per visit
Annual vision examinations $10 per visit
Emergency room $50 per visit
Inpatient hospital care Nothing

 

Summary of Benefits Download Summary of Benefits
Prescription Drug Coverage

Your plan includes prescription drug coverage through our Blue MedicareRxSM (PDP) plan. Covered medications are separated into three tiers, and the amount you pay depends on the medication's tier. You pay the following until your total yearly drug costs reach $2,850. For more information, download the Summary of Benefits.

Prescription Drug Benefit You Pay (In-Network Costs)
Retail pharmacies
$10 for Tier 1
$20 for Tier 2
$35 for Tier 3
Mail service pharmacy (up to a 90-day supply)
$20 for Tier 1
$40 for Tier 2
$70 for Tier 3
Summary of Benefits Summary of Benefits




Summary of Benefits Mail Service Order Form




Summary of Benefits List of Covered Drugs