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True Blue Rx Gem (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for True Blue Rx Gem (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on True Blue Rx Gem (HMO) in 2025, please refer to our full plan details page.
True Blue Rx Gem (HMO) is a HMO plan offered by Gemstone Holdings, Inc. available for enrollment in 2025 to people living in Select Counties in Idaho. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that True Blue Rx Gem (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 True Blue Rx Gem (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 True Blue Rx Gem (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $37.00. 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 $175.00 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 $4800.00 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 True Blue Rx Gem (HMO) plan has a $175 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will pay a $10 copay at standard and mail order pharmacies. For standard generic drugs, you will pay a $47 copay. Brand name drugs have a 50% coinsurance, and non-preferred drugs have a 31% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The True Blue Rx Gem (HMO) plan offers a wide range of benefits, including inpatient hospital stays with a copay, outpatient services, and coverage for emergency services. You'll find no copays for primary care visits, preventive services, and many dental services. The plan also includes coverage for hearing and vision services, with copays for exams and hearing aids. Additional benefits include coverage for home health services with no copay, and skilled nursing facility stays with a copay for certain days. The plan also offers coverage for over-the-counter items, and other services with prior authorization. However, some services like cardiac rehabilitation and certain types of hearing aids are not covered.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered with a copay of $325 for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while non-Medicare covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $300, observation services with a $300 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $20 copay for individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the True Blue Rx Gem (HMO) plan, with a $30 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the True Blue Rx Gem (HMO) plan, with prior authorization required for all ambulance services. Ground and air ambulance services have a copay of $270.00, and there is no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the True Blue Rx Gem (HMO) plan. Emergency Services have a $100 copay, and Urgently Needed Services have a $40 copay; both have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have no copay and no coinsurance.
Primary Care See details
The True Blue Rx Gem (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $30 copay, and physician specialist services with a copay between $0 and $30. Mental health specialty services and psychiatric services have a $20-$30 copay for individual or group sessions, while physical therapy and speech-language pathology services have a copay between $0 and $30. Opioid treatment program services have no copay, and additional telehealth benefits are available with a copay between $0 and $30.
Preventive Services See details
Preventive Services, including Medicare-covered services and annual physical exams, are covered by the True Blue Rx Gem (HMO) plan. Additional preventive services include fitness benefits with no copay. However, several services such as in-home safety assessments, personal emergency response systems, and others are not covered.
Hearing Services See details
Hearing Services include hearing exams, prescription hearing aids, and OTC hearing aids. Hearing exams have a $30 copay, and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids (all types) have a copay between $499 and $999, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams, eyewear, and upgrades. Eye exams have no copay for routine exams, but there is a $20 copay. Eyewear has no copay for contact lenses, but there is a $0-$35 copay, and eyeglasses (lenses and frames) have a $35 copay. Eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
The True Blue Rx Gem (HMO) plan covers dental services, including Medicare dental services for a $30 copay, and other dental services with no copay. The plan also offers coverage for specific services like oral exams, dental x-rays, cleanings, fluoride treatments, restorative services, and more; however, maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the True Blue Rx Gem (HMO) plan, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, and coinsurance between 0% and 20%. Other Medicare Part B Drugs and Chemotherapy/Radiation Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the True Blue Rx Gem (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0% to 20% coinsurance, and Prosthetics/Medical Supplies with coinsurance for Medicare-covered items. Diabetic Equipment has no copay for Diabetic Supplies, and 20% coinsurance for Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The True Blue Rx Gem (HMO) plan covers Diagnostic and Radiological Services, including diagnostic procedures with a copay of up to $30 and a coinsurance of up to 20%, and lab services with no copay. Diagnostic radiological services have a copay of up to $200, and therapeutic radiological services have a coinsurance of up to 20%. Outpatient X-ray services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the True Blue Rx Gem (HMO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the True Blue Rx Gem (HMO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the True Blue Rx Gem (HMO) plan, but require prior authorization. You will have no copay for days 1-20, a $203 copay for days 21-55, and no copay for days 56-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The "True Blue Rx Gem (HMO)" plan's other services benefit includes coverage for over-the-counter (OTC) items, with a maximum benefit of $50 every three months. Acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. Other 1 benefits are covered, with a maximum amount of $2500.00 every year, but require prior authorization.
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