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BlueMedicare Premier (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for BlueMedicare Premier (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on BlueMedicare Premier (HMO) in 2026, please refer to our full plan details page.
BlueMedicare Premier (HMO) is a HMO plan offered by Guidewell Mutual Holding Corporation available for enrollment in 2025 to people living in Orange County. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that BlueMedicare Premier (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about BlueMedicare Premier (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For BlueMedicare Premier (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The BlueMedicare Premier (HMO) prescription drug plan features an annual drug deductible of $615. Beneficiaries enjoy no copay for Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs filled at standard pharmacies or via standard mail order. This cost-saving benefit applies to both 1-month and 3-month supplies of these low-tier medications. For brand-name and specialty drugs, your costs are determined by coinsurance. Tier 3 preferred brands require a 21% coinsurance, while Tier 4 non-preferred drugs carry a 30% coinsurance for 1-month and 3-month standard fills. Specialty medications under Tier 5 are covered at a 25% coinsurance for a 1-month supply.
Additional Benefits
The BlueMedicare Premier (HMO) plan offers comprehensive coverage for essential medical services with predictable out-of-pocket costs and no coinsurance for many services. Members enjoy no copay for primary care physician visits, routine vision and hearing exams, and home health services. Specialist visits, emergency care, and outpatient services require low-to-moderate copays, while inpatient hospital stays feature a daily copay for the first seven days followed by no copay. For supplemental care, the plan provides preventive and comprehensive dental services with no copay, alongside an annual allowance of up to $225 for eyewear with no copay. Prescription hearing aids are covered with copays ranging from $350 to $1,825, and durable medical equipment features no copays with coinsurance up to 20%. While many diagnostic and routine services require no copay, some specialized treatments like dialysis and therapeutic radiology require a 20% coinsurance.
Inpatient Hospital See details
BlueMedicare Premier (HMO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization. Acute care requires a $185 daily copay for days 1-7 and no copay for days 8 and beyond, while psychiatric care requires a $300 daily copay for days 1-7 and no copay for days 8-90. Non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
BlueMedicare Premier (HMO) outpatient services are covered with no coinsurance, featuring a $0 to $175 copay for outpatient hospital services and a $110 copay per stay for observation services. Ambulatory surgical center and blood services require no copay and no coinsurance, while outpatient substance abuse sessions carry a $30 copay.
Partial Hospitalization See details
BlueMedicare Premier (HMO) covers partial hospitalization services with a $50.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
BlueMedicare Premier (HMO) covers ambulance services with prior authorization, requiring a copay of no copay to $275 with no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. For transportation services, some services are covered, but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
BlueMedicare Premier (HMO) covers emergency services with a $110 copay (waived if admitted within 48 hours) and no coinsurance, and urgently needed services with a $50 copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to a $25,000 maximum limit with a $110 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
BlueMedicare Premier (HMO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $0 to $55 copay and no coinsurance. Physical, occupational, and mental health therapies are covered with copays up to $45 and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by BlueMedicare Premier (HMO) with no copays and no coinsurance for covered benefits like kidney disease education, diabetes self-management training, and memory fitness. However, several services are not covered, including annual physical exams, health education, and personal emergency response systems.
Hearing Services See details
BlueMedicare Premier (HMO) covers routine hearing exams and fitting evaluations with no copay, no coinsurance, and a required referral. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $350.00 to $1,825.00 for up to two devices per year, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
BlueMedicare Premier (HMO) provides partially covered vision services with no deductibles and no coinsurance, featuring a $0 copay for annual routine eye exams and a $0 to $55 copay for other exams, though other eye exam services are not covered. Eyewear, including contacts, frames, lenses, and upgrades, is covered with no copay up to a $225 annual maximum.
Dental Services See details
BlueMedicare Premier (HMO) partially covers dental services, offering Medicare-covered dental with a $55 copay and no coinsurance, and other preventive and comprehensive services with no copay and no coinsurance. Sub-services that are not covered under this plan include other diagnostic dental services, adjunctive general services, maxillofacial prosthetics, implant services, fixed prosthodontics, and orthodontics.
Home Infusion bundled Services See details
BlueMedicare Premier (HMO) covers home infusion bundled services with prior authorization required, featuring a 0% to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Part B insulin drugs are covered with a $35 copay and 0% to 20% coinsurance, while other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by BlueMedicare Premier (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
BlueMedicare Premier (HMO) covers medical equipment with no copays across all categories, though prior authorization is required for certain items. Durable medical equipment and prosthetic devices carry a coinsurance of 0% to 20%, while medical supplies and diabetic equipment have no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by BlueMedicare Premier (HMO) with prior authorization and referrals required. Diagnostic tests and procedures feature no coinsurance and a copay of $0 to $50, therapeutic radiological services require a minimum 20% coinsurance, and lab services, outpatient X-rays, and diagnostic radiological services are available with no copay.
Home Health Services See details
Home Health Services are covered under the BlueMedicare Premier (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by BlueMedicare Premier (HMO) with no coinsurance, although only some services are covered in practice. The sub-services that are not covered include cardiac rehabilitation ($25 copay), intensive cardiac rehabilitation ($50 copay), pulmonary rehabilitation ($20 copay), and supervised exercise therapy for peripheral artery disease ($20 copay), all of which require prior authorization and referrals.
Skilled Nursing Facility (SNF) See details
BlueMedicare Premier (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required and additional days beyond the Medicare-covered limit are not covered. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100.
Other Services See details
Other Services are not covered under BlueMedicare Premier (HMO), as acupuncture, over-the-counter (OTC) items, and meal benefits are all excluded from coverage.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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