True Blue Rx Gem (HMO)

H1350 - 024 - 2
3.5 out of 5 stars (3.5 / 5)

True Blue Rx Gem (HMO) is a Medicare Advantage Plan by Blue Cross of Idaho.

This page features plan details for 2025 True Blue Rx Gem (HMO) H1350 – 024 – 2 available in Select Counties in Idaho.

Locations

True Blue Rx Gem (HMO) is offered in the following locations.

Plan Overview

True Blue Rx Gem (HMO) offers the following coverage and cost-sharing.

Insurer:Blue Cross of Idaho
Health Plan Deductible:$0
MOOP:$4,800 In-network
Drugs Covered:Yes

Ready to sign up for True Blue Rx Gem (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

True Blue Rx Gem (HMO) has a monthly premium of $61.00. 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
$185.00 $61.00 $0.00 $ $
Please Note:
  • 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

True Blue Rx Gem (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $175.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

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 DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $175.00 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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

True Blue Rx Gem (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Endodontics
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
  • Implant Services
    • In-Network: No Coins – 300.00 Copay (Authorization Required)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Periodontics
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
  • Prosthodontics, fixed
    • In-Network: No Coins – 300.00 Copay (Authorization Required)
  • Prosthodontics, removable
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
  • Restorative Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – – Copay
  • Fluoride Treatment
    • In-Network: No Coins – – Copay
  • Oral Exams
    • In-Network: No Coins – – Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – – Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • $0-200 copay (Authorization Required)
  • Lab services
    • $15 copay (Authorization Required)
  • Diagnostic tests and procedures
    • $0-30 copay or 0-20% coinsurance (Authorization Required)
  • Lab services
    • $0 copay (Authorization Required)
    • $10 copay (Authorization Required)
  • Outpatient x-rays
    • $15 copay (Authorization Required)

Doctor visits

  • Primary
    • $0-10 copay per visit
    • $0 copay
  • Specialist
    • $0-40 copay per visit
    • $0-30 copay per visit

Emergency care/Urgent care

  • Emergency
    • $100 copay per visit (always covered)
  • Urgent care
    • $40 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • $30 copay
    • $40 copay

Ground ambulance

    • $270 copay
    • $325 copay
    • $265 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • $30 copay
  • Fitting/evaluation
    • $0 copay
  • Medicare-Covered Hearing Exam
    • $40 copay
  • Hearing aids
    • $499-999 copay (Limits Apply)

Inpatient hospital coverage

    • $325 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • $360 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • $350 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $4,800 In-network
    • $5,200 In-network
    • $5,500 In-network

Medical equipment/supplies

  • Diabetes supplies
    • $0 copay per item
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 0-20% coinsurance per item (Authorization Required)
    • 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient individual therapy visit
    • $20 copay
  • Inpatient hospital – psychiatric
    • $350 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • $30 copay
    • $40 copay
  • Outpatient individual therapy visit with a psychiatrist
    • $30 copay
  • Inpatient hospital – psychiatric
    • $325 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • $360 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • $20 copay
  • Outpatient individual therapy visit with a psychiatrist
    • $40 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $0-300 copay per visit (Authorization Required)

Preventive care

    • $0 copay

Rehabilitation services

  • Occupational therapy visit
    • $40 copay
  • Physical therapy and speech and language therapy visit
    • $0-30 copay
  • Occupational therapy visit
    • $30 copay
  • Physical therapy and speech and language therapy visit
    • $40 copay

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $203 per day for days 21 through 55
      $0 per day for days 56 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Routine eye exam
    • $20 copay (Limits Apply, Authorization Required)
  • Upgrades
    • $0 copay (Limits Apply, Authorization Required)
  • Eyeglass frames
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Other
    • Not covered
  • Contact lenses
    • $0-35 copay (Limits Apply, Authorization Required)
  • Eyeglasses (frames and lenses)
    • $35 copay (Limits Apply, Authorization Required)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for True Blue Rx Gem (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

Need more information on True Blue Rx Gem (HMO)? See 2025 True Blue Rx Gem (HMO) at MedicareAdvantageRX.com.

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