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Medicare PPO Blue ValueRx (PPO)

Download 2013 Summary of Benefits

Monthly Plan Premium $66.10*

Call us:
1-800-678-2265
TTY: 1-800-522-1254

Hours of operation:
7 days a week
8 a.m. - 8 p.m.

Or have us call you.

Benefits at a Glance

	Medicare PPO Blue^SM ValueRx
Monthly Plan Premium	$66.10¹
Plan Information	In-Network	Out-of-Network
*Medical*
Doctor Office Visits	$0—$20 copay	$0—$20 copay
Specialist Office Visits	$0—$40 copay	$0—$40 copay
Medicare Preventive Services	$0 copay	$0 copay
Annual Medical Out-of-Pocket Maximum	In-network: $3,400 for Medicare-covered services Combined in and out-of-network: $3,400 for Medicare-covered services
Inpatient Care	Days 1—10: $200 copay per day	Days 1—10: $200 copay per day
Outpatient Services / Surgery	$0—$200 copay	$0—$200 copay
Diagnostic Procedures, Tests and Lab Services	$20 copay per day for lab; $150 copay per day for certain high-tech imaging, and $0 copay for X-rays and other diagnostic tests	$20 copay per day for lab; $150 copay per day for certain high-tech imaging, and $0 copay for X-rays and other diagnostic tests
Emergency Care	$0—$65 copay	$0—$65 copay
*Other Preventive Services*
Annual Routine Vision Exam	$40 copay for 1 routine test per year	$40 copay for 1 routine test per year
Eyeglasses Benefit	$150 limit for eyewear every two years
Annual Routine Hearing Exam	$20—$40 copay for 1 routine test per year	$20—$40 copay for 1 routine test per year
Hearing Aid Benefit	No coverage
Annual Fitness Benefit	$150 toward fitness club membership per year
Weight Loss Benefit	Up to $150 toward fees paid for qualified Weight Watchers^®'' or hospital-based weight loss programs
*Prescription Drug Coverage*		Cost
Annual Deductible		$0 Tiers 1 and 2; $220 Tiers 3, 4, and 5
Initial Coverage		30-day retail	90-day mail order
Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Drugs		$6 copay $12 copay $45 copay $90 copay 27% of the cost	$6 copay $24 copay $90 copay $180 copay 27% of the cost
Coverage Gap		For covered generics, you pay 79% of the plan's costs. For covered brand drugs, you pay no more than 47.5% of the plan's costs (excluding dispensing fees)
Catastrophic Coverage		You pay the greater of: $2.65 copay for generics or drugs treated like generic drugs $6.60 copay for brands 5% of the cost

1. Your monthly premium will be different if you qualify for Extra Help from Medicare.

As a Medicare PPO Blue ValueRx plan member, you get additional benefits beyond Original Medicare, such as:

Coverage for routine hearing exams and vision care
Allowance toward eyewear
Prevention and wellness programs
Worldwide coverage for emergency care

Medicare PPO Blue ValueRx also offers Medicare Part D prescription drug coverage. This makes it easy for you to get your medical and prescription benefits from one plan. See Medicare Advantage Prescription Drug Coverage for more information.

Visitor/Travel Program

Medicare PPO Blue ValueRx offers a Visitor/Travel Program that includes in-network benefits and cost-sharing when you receive treatment for covered services from participating Blue Medicare Advantage PPO network providers outside of Massachusetts in the following states: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Indiana, Kentucky, Maine, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin, and West Virginia.

Under Medicare Advantage rules, if you are absent from the service area for more than six (6) months, you must be disenrolled. However, in areas where we offer the Visitor/Travel Program you may remain in the plan while out of our service area for up to twelve (12) months.

In some cases, network providers are available in select areas of the state.

To locate a participating network provider:

Call the Member Service phone line during regular business hours, or
Call 1-800-810-BLUE to find a Blue Medicare Advantage PPO provider, or
Visit the Doctor Hospital Finder at www.bcbs.com to find a Blue Medicare Advantage PPO provider.

Summary of Benefits and Evidence of Coverage

* Your monthly premium will be different if you qualify for Extra Help from Medicare.