2025 NYSHIP Plan Comparison
Disclaimer: Please visit your HMO's website for the most up-to-date benefit information and any mid-year prescription drug formulary changes.
| Highmark Blue Cross Blue Shield - Medicare Advantage Plan (View Drug Formulary) | |
|---|---|
| Office Visits | $10 per visit [1] |
| Annual Adult Routine Physicals | No copayment |
| Well Child Care | |
| Specialty Office Visits | $30 per visit |
| Diagnostic/Therapeutic Services | |
| Radiology | $30 per test [2] |
| Lab Tests | No copayment [2] [3] |
| Pathology | No copayment |
| EKG/EEG | $30 per test |
| Radiation | $30 per test [2] |
| Chemotherapy | No copayment [2] |
| Dialysis | No copayment |
| Women's Health Care/Reproductive Health | |
| Pap Tests | No copayment |
| Mammograms | No copayment |
| Prenatal Visits | No copayment |
| Postnatal Visits | No copayment |
| Bone Density Tests | No copayment |
| Breastfeeding Services and Equipment | No copayment for classes; equipment not covered. |
| External Mastectomy Prosthesis | 20% coinsurance, one prosthesis per affected breast per year |
| Family Planning Services | $10 PCP, $30 specialist |
| Infertility Services | Not covered |
| Contraceptive Drugs | Applicable Rx copayment |
| Contraceptive Devices | Part B Medical: No copayment [4] |
| Inpatient Hospital Surgery | No copayment [2] |
| Physician | |
| Facility | |
| Outpatient Surgery | |
| Hospital | $75 per visit [2] |
| Physician's Office | $10 PCP/$30 specialist |
| Outpatient Surgery Facility | $75 per visit [2] |
| Weight Loss/Bariatric Surgery | See Outpatient Surgery or Inpatient Hospital Surgery |
| Emergency Department | $65 per visit [5] |
| Urgent Care Facility | $35 per visit [5] |
| Ambulance | $100 per trip [2] |
| Telehealth | Virtual Care PCP/Specialist: $10/$30 per visit with an in-network provider |
| Virtual Portal | Well360 Virtual Health: $30 Specialist/$35 Urgent Care/$40 Behavioral Health per visit |
| Outpatient Mental Health | $40 per visit [2] |
| Individual | |
| Group | |
| Inpatient Mental Health | No copayment [2] [6] |
| Outpatient Drug/Alcohol Rehab | $40 per visit, unlimited [2] |
| Inpatient Drug/Alcohol Rehab | No copayment [2] [6] |
| Durable Medical Equipment | $0 compression stockings, 20% coinsurance on all other items [2] |
| Prosthetics | 20% coinsurance [2] [7] |
| Orthotics | 20% coinsurance [2] [7] |
| Rehabilitative Care, Physical, Speech and Occupational Therapy | |
| Inpatient | No copayment, unlimited [2] |
| Outpatient Physical or Occupational Therapy | $20 per visit, unlimited |
| Outpatient Speech Therapy | $20 per visit, unlimited |
| Diabetic Supplies | No copayment, Part B coverage: glucose monitors, lancets and test strips |
| Retail | |
| Mail Order | |
| Insulin and Oral Agents | Applicable Rx copayment [2] [8] |
| Retail | |
| Mail Order | |
| Diabetic Shoes | No copayment, when medically necessary [9] |
| Hospice | Covered by Medicare |
| Skilled Nursing Facility | No copayment, 100 days max per benefit period [2] |
| Prescription Drugs | |
| Retail | $0 Tier 1, $15 Tier 2, $30 Tier 3, $50 Tier 4, $50 Tier 5 |
| Mail Order | $0 Tier 1, $30 Tier 2, $60 Tier 3, $100 Tier 4, Tier 5 not covered |
| Additional Prescription Drug Related Information | Part D Rx Plan: Once your total drug costs (what you and your plan have paid, combined) reach $2,000, you will pay $0 for Part D prescriptions for the remainder of the plan year. Receive up to a 100-day supply (retail and mail order) of Tier 1 and 2 drugs and up to a 90-day supply (retail and mail order) of Tier 3 and 4 drugs. Tier 5 drugs are limited to a 31-day supply (retail only). |
| Specialty Drugs | Your provider may supply and administer drugs in the office. These are Medicare-covered Part B drugs and have no copayment. Part D Rx Plan: You pay the applicable tier copayment. [2] |
| Additional Benefits | |
| Annual Out-of-Pocket Maximum (In-Network Benefits) | $3,000 per year |
| Dental | $200 allowance |
| Vision | $200 allowance (frames, lenses, contacts), $0 copayment for one routine exam per year. [10] |
| Hearing Aids | $699 copayment per aid for advanced model, $999 copayment per aid for premium model. [11] |
| Out of Area | Plan covers emergency care, urgently-needed care and kidney dialysis services outside the service area. |
| Additional Benefits HMOs (as applicable) | |
| Fitness Benefit | No copayment |
| Plan Highlights for 2025 | New lower Part D Rx out-of-pocket limit of $2,000. $0 FitOn fitness benefit. $200 allowance for eyewear through Davis Vision and $200 allowance for dental care. |
| Participating Physicians | Our network has more than 9,800 physicians and health care professionals. |
| Affiliated Hospitals | All Western New York hospitals are under contract. Members may be directed to other hospitals if medically necessary. |
| Pharmacies and Prescriptions | Part D Rx Plan: Includes a nationwide network of over 65,000 participating pharmacies. |
| Medicare Coverage | Medicare-primary NYSHIP enrollees are required to enroll in Senior Blue HMO, our Medicare Advantage Plan. To qualify, you must enroll in Medicare Parts A & B and live in the service area. |