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

Foot Care Foot exams and Foot exams and Foot exams and
(Podiatry services) treatment if you have treatment if you have treatment if you have
diabetes-related nerve diabetes-related nerve diabetes-related nerve
damage and/or meet damage and/or meet damage and/or meet
certain conditions: certain conditions: certain conditions:
$20–40 copay $15–35 copay In-network:

Referral from your doctor Referral from your doctor $15–35 copay
may be required. may be required. Out-of-network:
$65 copay
Referral from your doctor
may be required.
Diabetes Supplies
and Services
Diabetes monitoring You pay nothing* You pay nothing* In-network:
supplies: You pay nothing*
Out-of-network:
20% of the cost*
Diabetes self- You pay nothing You pay nothing In-network:
management training: You pay nothing
Out-of-network:
20% of the cost
Therapeutic shoes or You pay nothing You pay nothing In-network:
inserts: You pay nothing
Out-of-network:
20% of the cost
Durable Medical 20% of the cost 10% of the cost In-network:
Equipment Authorization rules may Authorization rules may 10% of the cost
(wheelchairs, apply. apply. Out-of-network:
oxygen, etc.) 20% of the cost

Authorization rules may
apply.

Prosthetic Devices
(braces, artificial
limbs, etc.)
Prosthetic devices: 20% of the cost 10% of the cost In-network:
10% of the cost
Out-of-network:
20% of the cost
Related medical 20% of the cost 10% of the cost In-network:
supplies: 10% of the cost
Out-of-network:
20% of the cost

*Coverage for diabetic test strips is limited to Johnson and Johnson (OneTouch products) and Roche
Diagnostics (Accu-Chek products) when purchased at participating retail and mail-order pharmacies.
No coverage for other test strips.
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