True Blue Valor (HMO)
H1350 - 006 - 0
(4.5 / 5)
True Blue Valor (HMO) is a Medicare Advantage (Part C) Plan by Blue Cross of Idaho.
This page features plan details for 2024 True Blue Valor (HMO) H1350 – 006 – 0 available in Select Counties in Idaho.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
True Blue Valor (HMO) is offered in the following locations.
Plan Overview
True Blue Valor (HMO) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross of Idaho |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,000 In-network |
| Drugs Covered: | No |
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Premium Breakdown
True Blue Valor (HMO) has a monthly premium of $34.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $34.00 | $0.00 | $208.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
True Blue Valor (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,000 In-network |
| No |
| In-network | No |
| $0-150 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $25 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-30 copay (Authorization is not required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-200 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $499-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Office visit | $0.00 (Authorization is not required.) (Referral is not required.) |
| Oral exam | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $20 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0-35 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $35 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Occupational therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| $175 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 10% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 10% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-10% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-10% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-10% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $100 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $100 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| $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 is required.) (Referral is not required.) |
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Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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