Bluechip For Medicare 2015 Plan Selection Form printable pdf download

BlueCHiP for Medicare

2015 Plan Selection Form

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Date:

Member Name: _________________________________________________________________________________

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Member Number:

Email Address: __________________________________________________________________________________

Instructions:

• To change to a new BlueCHiP for Medicare plan, please put a check next to your new plan choice below.

• To add BlueCHiP for Medicare Dental to your existing plan or your new plan, please choose BlueCHiP

for Medicare Dental below.

• If you do not want to make any changes for 2015, you do not need to send us this form.

The information below provides a brief summary of our plans. Please refer to your plan materials for

more details, or call the BlueCHiP for Medicare Concierge Team at the number on the back page.

___ BlueCHiP for Medicare Core (HMO)

$0 Monthly Premium

Office Visit Copayments:

$0 PCMH/$10 Primary Care Physician; $30 Specialist

Emergency Room:

$65 copayment per visit

Inpatient Hospital:

Days 1-5: $180/day

Days 1-4: $180/day

Inpatient Mental Health:

Durable Medical Equipment:

20% coinsurance

In-Network Out-of-pocket Maximum:

$3,950; all Medicare-covered services apply

Prescription Drug Coverage:

Medicare Part B coverage only (20% coinsurance)

___ BlueCHiP for Medicare Select (HMO)

– NEW!

$0 Monthly Premium

Office Visit Copayments:

$0 Primary Care Physician; $45 Specialist

Emergency Room:

$65 copayment per visit

Inpatient Hospital:

Days 1-5: $285/day

Days 1-4: $285/day

Inpatient Mental Health:

Durable Medical Equipment:

20% coinsurance

$3,850; all Medicare-covered services apply

In-Network Out-of-pocket Maximum:

Prescription Drug Coverage:

$0/$45/$95/28% ($200 deductible for tiers 2, 3, 4)

Please write the full name of the primary care physician you have chosen from within the Select network.

___ BlueCHiP for Medicare Value (HMO-POS)

$0 Monthly Premium

Office Visit Copayments:

$0 PCMH/$25 Primary Care Physician; $45 Specialist

Emergency Room:

$65 copayment per visit

Inpatient Hospital:

Days 1-5: $345/day

Inpatient Mental Health:

Days 1-4: $345/day

Durable Medical Equipment:

20% coinsurance

In-Network Out-of-pocket Maximum:

$5,000; all Medicare-covered services apply

Prescription Drug Coverage:

$2/$45/$95/25% ($320 deductible for tiers 2, 3, 4)

20% coinsurance for most covered services

Point-of-service Out-of-network Benefit:

Point-of-service Out-of-pocket Maximum:

$5,000

*Must receive care with Select network of providers.

H4152_planselectionform399 Approved

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Bluechip For Medicare 2015 Plan Selection Form

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