|BluePathway Plan 1 (HMO)
|$0 Monthly Premium|
The BluePathway Plan 1, offers all of the benefits of Original Medicare plus prescription drug coverage in one, convenient $0 premium plan. There are even more ways to get healthier and save with an allowance for over-the-counter (OTC) non-prescription products, fitness benefits, telehealth services, and coverage for chiropractic, acupuncture, and therapeutic massage.
|2022 Benefit Chart
||BluePathway Plan 1 (HMO)
|Inpatient Hospital Care||$175/day, Days 1 through 5
$875 max out-of-pocket
|Prescription Drug Coverage||Included|
|Dental Plan||$1000 limit for two routine exams, two sets of bitewing x-rays and two cleanings per year|
|Routine Hearing Exam||$0 (with preferred provider)|
|Hearing Aids||$699/$999 copay per ear with $0 upgrade to rechargeable hearing aids for certain models through TruHearing®.|
|Vision Plan||$0 routine eye exam plus $200 allowance for eyewear every two years (with preferred provider). Vision plan administered by Davis Vision™.|
|Welvie||An online surgery decision support program that helps you decide on, prepare for, and recover from surgery. Available to you at no added cost. Learn more.|
|Telehealth Services||$0 copay to see a board-certified doctor, counselor, or psychiatrist on a computer or mobile device using the BlueCare Anywheresm Telehealth app.|
|Over the Counter (OTC)||$50 quarterly allowance for non-prescription OTC products like vitamins, sunscreen, pain relievers, cough/cold medicine, and bandages. The benefit allowance must be used for plan-approved items. Learn more.|
2022 BluePathway Plan 1 Coverage Details
Doctor’s Office Visits:
How much does it cost for a doctor’s office visit?
Under BluePathway Plan 1, you will pay a $0 copay per visit with your primary care provider and a $20 copay per visit to see a specialty care doctor, such as a heart doctor.
Do I need a referral to see a specialty care doctor?
Yes. You will need to have a referral from your primary care provider sending you to see a specialty care doctor. (More information is available in Chapter 3 of your Evidence of Coverage booklet).
Will I ever be billed more than a copay for an office visit?
It will depend on what the doctor does during your office visit. Additional services done at the time of the visit may have separate cost-sharing that you would need to pay. Be sure to talk to your doctor during the visit.
Durable Medical Equipment:
How much does it cost for medical equipment I may need?
Under BluePathway Plan 1, you will pay 20% of the allowed charges. To avoid being charged more, be sure to have the ordering doctor check with BCBSAZ to see if prior authorization is needed.
Urgently Needed Care:
How much does it cost to be seen at an urgent care facility?
Urgent care visits are $20 copay per visit to an urgent care facility.
Do I have to see an urgent care doctor that is in-network with BluePathway Plan 1?
No. Urgently needed care may be received from an in-network or out-of-network doctor when network doctors are not available or difficult to get to.
Am I covered if I need urgent care while traveling outside the United States?
No. Coverage for visits to urgent care facilities is limited to the United States and its territories.
How much does it cost to be seen in the emergency room?
Under BluePathway Plan 1, you will pay a $120 copay at the time of service.
Is there a time when my copay would be waived?
Yes. The copay is waived if you are admitted to the hospital through the emergency room. Your copay will also be waived if you are admitted to the hospital within one day of being seen in the emergency room for the same condition.
Am I covered if I have to go to the emergency room while traveling outside the United States?
No. Coverage for emergency room visits is limited to the United States and its territories.
Inpatient Hospital Care:
If I am admitted to the hospital, how much will I have to pay?
Under BluePathway Plan 1, you will pay a $175 copay per day for inpatient days 1 through 5. If you remain in the hospital another 6 to 364 days, there is no copay due.
Your out-of-pocket maximum per admission is $875.
Copays apply to each inpatient admission.
Will my primary care provider take care of me in the hospital?
It will depend if your doctor has privileges to see patients in the hospital you were admitted to. A doctor called a hospitalist may be assigned to take care of you when you are admitted to the hospital.
Skilled Nursing Facility (SNF):
If I am admitted to a skilled nursing facility, how much will I have to pay?
Days 1-20: $0 copay per day
Days 21-40: $188 copay per day
Days 41-100: $0 copay per day
How many days in a skilled nursing facility are covered by the plan?
BCBSAZ covers up to 100 days each benefits period.
Do I get more benefits if I use all 100 days?
Yes. Your 100 days of benefits will restart when you have been out of a hospital or skilled nursing facility for 60 days in a row or longer.
Do I have to be in the hospital before I can be admitted to a skilled nursing facility?
Outpatient Prescription Drugs:
Do I have to pay a deductible for prescription drugs?
No. Under BluePathway Plan 1, there is no deductible for prescription drugs.
What is the Initial Coverage stage of my drug benefits?
The Initial Coverage stage is the first of three stages you can enter in a calendar year. You will stay in this stage until the total amount you have paid out-of-pocket and the total amount of what BCBSAZ has paid for prescription drugs equals $4,430.
What is the Coverage Gap stage of my drug benefits?
The Coverage Gap stage is the second of three stages you can enter in a calendar year. You will stay in this stage until the total amount you have paid out-of-pocket for prescription drugs equals $7,050.
What is the Catastrophic Coverage stage of my drug benefits?
The Catastrophic Coverage stage is the third and final stage you can enter in a calendar year. If you enter this stage, you will remain in it until the calendar year ends. Your share of the cost for covered drugs will either be coinsurance or copayment, whichever is the larger amount.
Coinsurance will be 5% of the cost of the drug.
$3.95 for a generic drug or a drug that is treated like a generic drug.
$9.85 for all other drugs.
How many cost-sharing drug tiers does the plan have?
Under BluePathway Plan 1, you will have 5 cost-sharing tiers:
Tier 1 - Preferred generic drugs
Tier 2 - Generic drugs
Tier 3 - Preferred brand drugs
Tier 4 - Non-preferred brand drugs
Tier 5 - Specialty drugs
What is a formulary?
A formulary is a list of drugs that are covered by BCBSAZ. Not all drugs are included in the formulary. Some drugs may have restrictions such as prior authorization, step therapy, and/or quantity limits.