Medicare PPO Blue PlusRx (PPO)

Download 2013 Summary of Benefits

Benefits at a Glance

	Medicare PPO Blue^SM PlusRx
Monthly Plan Premium	$136.10¹
Plan Information	In-Network	Out-of-Network
*Medical*
Doctor Office Visits	$0—$15 copay	$0—$40 copay²
Specialist Office Visits	$0—$30 copay	$0—$40 copay²
Medicare Preventive Services	$0 copay	$0—$40 copay or 20% of the cost²
Annual Medical Out-of-Pocket Maximum	In-network: $3,400 for Medicare-covered services Combined in and out-of-network: $5,100 for Medicare-covered services
Inpatient Care	Days 1—5: $150 copay per day $750 annual out-of-pocket maximum	20% of the cost²
Outpatient Hospital Care / Surgery	$0—$100 copay	20% of the cost²
Diagnostic Procedures, Tests and Lab Services	$0 copay for lab; $100 copay for certain high-tech imaging, and $0 copay for X-rays and other diagnostic tests	20% of the cost²
Emergency Care	$0—$65 copay	$0—$65 copay
*Other Preventive Services*
Annual Routine Vision Exam	$30 copay for 1 routine test per year	$40 copay² for 1 routine test per year
Eyeglasses Benefit	$150 limit for eyewear every two years	$150 limit² for eyewear every two years
Annual Routine Hearing Exam	$15—$30 copay for 1 routine test per year	$40 copay² for 1 routine test per year
Hearing Aid Benefit	Up to $400 limit every 3 years	Up to $400 limit² every 3 years
Annual Fitness Benefit	$150 toward fitness club membership per year	$150² 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	Up to $150² toward fees paid for qualified Weight Watchers^®'' or hospital-based weight loss programs
*Prescription Drug Coverage*		Cost
Annual Deductible		$0
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 30% of the cost	$6 copay $24 copay $90 copay $180 copay 30% 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.

2. After you pay your $500 out-of-network annual deductible for most Medicare-covered services (a separate office visit copay may apply).

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

Coverage for routine hearing exams and vision care
Allowances toward hearing aids and eyewear
Routine preventive dental care
Prevention and wellness programs
Worldwide coverage for emergency care

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

Visitor/Travel Program

Medicare PPO Blue PlusRx offers a Visitor/Travel Program which 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) consecutive 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, you can:

Call the Member Service phone line during regular business hours, or
Call 1-800-810-BLUE (2583) (TTY: 1-800-522-1254), to find a Blue Medicare Advantage PPO provider, or
Visit the Doctor Hospital Finder to find a Blue Medicare Advantage PPO provider.

Medicare PPO Blue PlusRx (PPO)

Benefits at a Glance

Visitor/Travel Program

Summary of Benefits and Evidence of Coverage