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BlueJourney HMO

Select a BlueJourney HMO plan that meets your needs.

Service area Essential Value Premier
 
Enroll Online Enroll Online Enroll Online
Monthly premium $0 $60 $116
In-network deductible N/A N/A N/A
Maximum out-of-pocket (MOOP) $7,500 $5,000 $4,500
Primary Care Physician Office Visits - in person or telehealth $5 copay $5 copay $5 copay
Physician specialist - in person or telehealth $35 copay $30 copay $20 copay
Urgent care $40 copay $50 copay $30 copay
Inpatient hospital stay $200 per day for days 1-8 $150 per day for days 1-5 $100 per day for days 1-5
Outpatient Surgery $375 copay $300 copay $225 copay
Ambulatory Surgical Center (ASC) $275 copay $200 copay $75 copay
Emergency care $90 copay $90 copay $90 copay
Lab services $0-$25 copay/visit $0-$20 copay/visit $0-$20 copay/visit
X-rays $50 copay $25 copay $25 copay
High-tech imaging (MRI/CT scan) $250 copay $150 copay $75 copay
Diabetes self-monitoring training and supplies $0 copay $0 copay $0 copay
Hearing services 
(routine fitting and exam)
$0 copay for routine exam 
$0 copay fitting/3 years
$0 copay for routine exam 
$0 copay fitting/3 years
$0 copay for routine exam 
$0 copay fitting/3 years
Hearing aids $800 allowance/3 years $800 allowance/3 years $800 allowance/3 years
Expanded dental benefits 
(two cleanings per calendar year)
$10 copay in-network cleaning and X-rays covered, 50% coinsurance for nonroutine, restorative, endodontics, and simple extractions services 
$2,000 annual allowance
$10 copay in-network cleaning and X-rays covered, 50% coinsurance for nonroutine, restorative, endodontics, and simple extractions services 
$2,000 annual allowance
$10 copay in-network cleaning and X-rays covered, 50% coinsurance for nonroutine, restorative, endodontics, and simple extractions services 
$2,000 annual allowance
SilverSneakers®1 $0 copay $0 copay $0 copay
Flexible debit card for over-the-counter drugs and supplies (OTC)2 $25 monthly allowance retail or mail order (cannot be carried over from month to month) $25 monthly allowance retail or mail order (cannot be carried over from month to month) $25 monthly allowance retail or mail order (cannot be carried over from month to month)
Vision services hardware allowance and contact lenses coverage

$125 allowance for eyeglass frames or contact lenses every year3

$125 allowance for eyeglass frames or contact lenses every year3

$125 allowance for eyeglass frames or contact lenses every year3

Routine vision(one annual eye exam)

$20 copay

$20 copay

$20 copay

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Plan Info

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Must use a SilverSneakers® facility.

Qualifying OTC retailers: Walmart, Rite Aid, CVS, and Walgreens.

Members pay the balance of charges after a $125 routine vision allowance is applied. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

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Updated October 1, 2021

Y0016_22WBSTAPP_C

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