Empire MediBlue Plus (HMO)
H8432 - 008 - 7
(3.5 / 5)
Empire MediBlue Plus (HMO) is a Medicare Advantage Plan by Empire BlueCross BlueShield.
This page features plan details for 2023 Empire MediBlue Plus (HMO) H8432 – 008 – 7 available in Kings County.
IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Empire MediBlue Plus (HMO) is offered in the following locations.
Plan Overview
Empire MediBlue Plus (HMO) offers the following coverage and cost-sharing.
| Insurer: | Empire BlueCross BlueShield |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,300 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $350.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Empire MediBlue Plus (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Empire MediBlue Plus (HMO) has a monthly premium of $16.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $16.00 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Empire MediBlue Plus (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $350.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $16.00 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $350.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | |
| 2 (Generic) | $15.00 copay | $20.00 copay | $15.00 copay | |
| 3 (Preferred Brand) | $42.00 copay | $47.00 copay | $42.00 copay | |
| 4 (Non-Preferred Drug) | $94.00 copay | $99.00 copay | $94.00 copay | |
| 5 (Specialty Tier) | 27% | 27% | 27% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | |
| 2 (Generic) | $45.00 copay | $60.00 copay | $45.00 copay | |
| 3 (Preferred Brand) | $126.00 copay | $141.00 copay | $126.00 copay | |
| 4 (Non-Preferred Drug) | $282.00 copay | $297.00 copay | $282.00 copay | |
| 5 (Specialty Tier) |
Gap Coverage Phase
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Empire MediBlue Plus (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | Not covered (no limits) |
| Extractions: | Not covered (no limits) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | Not covered (no limits) |
Dental (preventive)
| Cleaning: | Not covered (no limits) |
| Dental x-ray(s): | Not covered (no limits) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | Not covered (no limits) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $200-250 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0-150 copay (authorization required) (referral required) |
| Lab services: | $0 copay (authorization required) (referral required) |
| Outpatient x-rays: | $55-100 copay (authorization required) (referral required) |
| Outpatient x-rays: | $75-100 copay (authorization required) (referral required) |
| Outpatient x-rays: | $50-90 copay (authorization required) (referral required) |
Doctor visits
| Primary: | $10 copay per visit |
| Primary: | $20 copay per visit |
| Specialist: | $50 copay per visit (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $60 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $50 copay (authorization required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $330 copay | |
| $265 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered (no limits) |
| Hearing aids – inner ear: | Not covered (no limits) |
| Hearing aids – outer ear: | Not covered (no limits) |
| Hearing aids – over the ear: | Not covered (no limits) |
| Hearing exam: | $50 copay (authorization required) (referral required) |
Hospital coverage (inpatient)
| $480 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) (referral not required) | |
| $500 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| $0 copay or 30% coinsurance per visit (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $8,300 In-network | |
| $7,550 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $465 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | $40 copay (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
| Outpatient individual therapy visit: | $40 copay (authorization required) (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $40 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $40 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | Not covered (no limits) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | Not covered (no limits) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $14.00 |
| Preventive dental: | Deductible: | N/A |
Package #2
| Preventive dental: | Monthly Premium: | $22.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $22.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $22.00 |
| Eyewear: | Deductible: | N/A |
Package #3
| Preventive dental: | Monthly Premium: | $43.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $43.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $43.00 |
| Eyewear: | Deductible: | N/A |
Ready to sign up for Empire MediBlue Plus (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST