Ah, I just looked. Years ago they had a 3rd tier level

Quote:

Coverage Gap The Coverage Gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130. After you enter the Coverage Gap , you pay 25% of the plan's cost for covered brand name drugs and 25% of the plan's cost for covered generic drugs until your costs total $6,550.
https://medicare.horizonblue.com/2021/shop-pl...MiOiIzMSJ9

Quote:

Horizon Medicare Blue Value w/Rx (HMO)
4.0 / 5
< Back to Plan Pricing
MONTHLY PREMIUM

$46.00

ENROLL
PLAN DETAILS
PLAN DOCUMENTS
BENEFIT TYPE IN NETWORK BENEFIT
Referrals Required No
PCP Required Yes
Annual Medical Deductible $0
Maximum Out-of-Pocket Responsibility $6,700 annually for services you receive from in-network providers
Hospital Care Inpatient:
$225 Copay per day for days 1 through 8
$113 Copay per day for day 9
$0 Copay for day 10 and beyond
Our plan covers an unlimited number of days for an inpatient hospital stay.

Covers inpatient substance use disorder

Outpatient:
20% of the cost for outpatient hospital services
Doctor Visits
Primary care physician (PCP): $10 Copay
Specialist visit: $40 Copay
No specialist referrals required
Preventive Care
$0 Copay

Our plan covers many preventive services, including:
Abdominal aortic aneurysm screening
Alcohol misuse screening and counseling
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral therapy)
Cardiovascular disease screenings
Cervical and vaginal cancer screening
Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy)
Depression screening
Diabetes self-management training (DSMT)
Glaucoma tests
Hepatitis C virus screening
HIV screening
Lung cancer screening
Medicare Diabetes Prevention Program (MDPP)
Medical nutrition therapy services
Obesity screening and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screening and counseling
Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots
"Welcome to Medicare " preventive visit (one-time)
Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered.


Annual Physical Exam $0 Copay
Emergency Care $90 Copay (worldwide)
Urgently Needed Services
$25 Copay for in-network urgent care center
$40 Copay for a physician's office or other setting
$90 Copay for worldwide coverage
Copay waived if admitted to a hospital within 24 hours for the same condition.

Diagnostic Services/ Labs/ Imaging Diagnostic Colonoscopy
$0 Copay at office or freestanding facility and outpatient hospital
Diagnostic radiology services (such as MRIs, CT scans):
$40 Copay at office or freestanding facility
20% of the cost for outpatient hospital
Lab Services:
$0 Copay for tests performed at participating facilities
20% of the cost for outpatient hospital
Diagnostic Mammogram
$0 Copay at office or freestanding facility and outpatient hospital
Diagnostic tests and procedures:
$40 Copay at office or freestanding facility
20% of the cost for outpatient hospital
Therapeutic Radiology:
$60 Copay at office or freestanding facility
20% of the cost for outpatient hospital
X-rays:
$40 Copay at office or freestanding facility
20% of the cost for outpatient hospital
Hearing Services Exam to diagnose and treat hearing and balance issues:
$40 Copay
Routine hearing exam (1per year):
$0 Copay
Fitting/Evaluation for hearing aid:
$0 Copay
Our plan pays up to $1,250 every year for hearing aids.
Routine hearing exam & hearing aid services must be coordinated through HearUSA. Plan covers $750 for purchase of hearing aid for one ear & $500 for purchase of hearing aid for second ear. Member is responsible for payment beyond the $1,250 coverage limit. One (1) year supply of batteries are included.
Dental Services We cover in-network routine dental services:
$0 Copay for cleaning (1 every six months)
$0 Copay for a full mouth x-ray, including bitewings (1 every 3 years)
$0 Copay for oral exam (1 every six months for up to 4 bitewings)
$0 Copay for restorations that include silver and/or composite fillings. Only one filling every 6 months on the same tooth/surface is covered.
Medicare covered dental services: $0 Copay
Vision Services Routine eye exam (1 every year)
$0 Copay
Eyeglasses or contact lenses after cataract surgery
$0 Copay
Glaucoma screening/annual retinal exam
$0 Copay
Exam to diagnose and treat diseases and conditions of the eye
$40 Copay
$100 eyewear reimbursement every 2 years for eyeglasses or contact lenses not associated with cataract surgery. Member is responsible for payment beyond $100 coverage limit.
Mental Health Services Inpatient:
$225 Copay per day for days 1 through 6
$178 Copay per day for days 7
$0 Copay for days 8 through 90
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital.
Outpatient:
$40 Copay for each individual/group therapy office visit
Skilled Nursing Facility (SNF) Our plan covers up to 100 days per benefit period.
$0 Copay for days 1 through 20
$125 Copay per day for days 21 through 100
Ambulance Ground ambulance (one way) $250 Copay
Air ambulance (one way): $250 Copay

Prescription Drug Coverage
Deductible : $445 per year

Preferred Pharmacy One-month supply

Tier 1 (Preferred Generic): $2 Copay
Tier 2 (Generic): $12 Copay
Tier 3 (Preferred Brand): $35 Copay
Tier 4 (Non-Preferred Drug): $65 Copay
Tier 5 (Specialty): 25% of the cost
Standard Pharmacy One- month supply

Tier 1 (Preferred Generic): $9 Copay
Tier 2 (Generic): $20 Copay
Tier 3 (Preferred Brand): $42 Copay
Tier 4 (Non-Preferred Drug): $75 Copay
Tier 5 (Specialty Tier): 25% of the cost
Standard Mail Order Three-month supply

Tier 1 (Perferred Generic): $3 Copay
Tier 2 (Generic): $18 Copay
Tier 3 (Preferred Brand): $105 Copay
Tier 4 (Non-Preferred Drug): $195 Copay
Tier 5 (Specialty): Not offered
You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.


Coverage Gap The Coverage Gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130. After you enter the Coverage Gap , you pay 25% of the plan's cost for covered brand name drugs and 25% of the plan's cost for covered generic drugs until your costs total $6,550.
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of:
5% of the cost, or
$3.70 Copay for generic (including brand drugs treated as generic) and a $9.20 Copay for all other drugs.
Fitness Program $200 yearly gym and / or yoga studio membership reimbursement
Foot Care (podiatry services) $40 Copay for Medicare covered foot exams and treatment
Home Health Care $0 Copay
Hospice $0 Copay for Hospice Care from a Medicare -certified hospice. You may have to pay part of the cost for drugs and respite care.
Medical Equipment/ Supplies Durable Medical Equipment (wheelchairs, oxygen equipment, etc):
20% of the cost
Related medical supplies:
20% of the cost
Prosthetic devices (braces, artificial limbs, etc):
20% of the cost
Diabetes monitoring supplies/therapeutic shoes or inserts:
$0 Copay
Diabetes self-management training:
$0 Copay
Nurse Line $0 Copay for a 24/7 Nurse Line is a confidential service that enables the member to speak with a registered nurse, toll free 24 hours a day to assist with health-related questions and concerns.
Outpatient Surgery 20% Coinsurance for outpatient facility
Telehealth $0 Copay for urgently needed services and behavioral health. Must access via preferred vendor.