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Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Diagnostic tests and $30 copay $10 copay In-network: $15 copay
procedures Out-of-network:
20% of the cost
Lab services: $30 copay $10 copay In-network: $15 copay
Out-of-network:
20% of the cost
Outpatient x-rays: $20 copay $10 copay In-network: $15 copay
Out-of-network:
20% of the cost

Hearing Service
Routine Exam—up to $20–40 copay depending $15–35 copay depending In-network:
one per year: on the service on the service $15–35 copay depending
on the service
Out-of-network:
$45 copay depending on
the service

Non Routine Exam: $20–40 copay depending $15–35 copay depending In-network:
on the service on the service $15–35 copay depending
on the service
Out-of-network:
$65 copay
Hearing Aids: Not covered Our plan pays up to Our plan pays up to $400
$400 every three years every three years for
for hearing aids hearing aids
Dental Services

Limited Medicare- $40 copay $35 copay In-network: $35 copay
covered dental services: Out-of-network:
$65 copay
Routine dental $40 copay $35 copay In-network: $35 copay
services: Out-of-network:
Single copay for visit $45 copay
that includes:
Cleaning (for up to 1
every six months)
Dental x-ray(s)* (for up
to 1 every six months)
Oral exam (for up to 1
every six months)

*Dental x-ray(s) coverage is limited to one set of bitewings every 6 months.

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