Managed Blue for Seniors
This plan is an option for retired employees. With this plan, you have the convenience of selecting a doctor who is close to your home. If you visit a specialist, you will need a referral from your primary care physician in order to receive full benefits. Otherwise, your coverage will be limited to Medicare benefits only. In most cases, you’re covered either in full or with a $15 copayment. This plan includes prescription drug coverage.
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Copayments
- Routine office visits: $15 per visit
- Routine vision exams (one per calendar year): $15 per visit
- Allergy care and testing: $15 per visit
- Cardiac rehabilitation services: $15 per visit
- Chiropractor services: $15 per visit
- Immunizations and injections: Nothing
- Diagnostic tests: Nothing
- X-rays and lab tests: Nothing
- Limited oral surgery: $15 per visit
Pharmacy Coverage
This plan includes prescription drug coverage. Covered medications are separated into three tiers, and the amount a member pays depends on the medication’s tier.
| Prescription Drug Benefit | Member Pays (In-Network Costs) |
|---|---|
| Retail pharmacies (up to a 30-day supply) | Tier 1 drugs: $10 Tier 2 drugs: $25 Tier 3 drugs: $45 |
| Mail order supply (up to a 90-day supply) | Tier 1 drugs: $20 Tier 2 drugs: $50 Tier 3 drugs: $115 |
Mental Health
Biologically Based Mental Conditions
- Inpatient admissions in a network general or mental hospital: Nothing
- Outpatient visits (No limit): $15 per visit
Non-Biologically Based Mental Conditions
- Inpatient admissions in a network general hospital: Nothing
- Inpatient admissions in a network mental hospital or substance use facility (after Medicare days end, up to 60 days per calendar year): Nothing
- Outpatient visits covered by Medicare: $15 per visit
Alcoholism Treatment
- Inpatient admissions in a network general hospital: Nothing
- Inpatient admissions in a network mental hospital or substance use facility (after Medicare days end, up to 60 days per calendar year plus 30 more days per calendar year): Nothing
- Outpatient visits covered by Medicare (after Medicare days end, up to 24 visits per calendar year plus 8 more visits per calendar year with a value of at least $500): $15 per visit
Additional Benefits
- Medicare-approved yearly gynecological exams: $15 per visit
- Medicare-approved ambulance service when medically necessary per one-way transport (copayment waived for emergency transport): $40 copayment
- Skilled nursing facility (100 days per benefit period): Nothing
- Rehabilitation hospital: $50 per admission Medicare-approved home health care as requested by a Managed Blue for Seniors physician: Nothing
- Medicare-approved outpatient physical, speech/language pathology, and occupational therapy:$15 per visit
- Medicare-approved durable medical equipment: $15 per item
Plan Documents
