< view all plans Click to print Text size: Click to decrease font size Click to increase font size Click to increase font size

Medicare PPO Blue SaverRx (PPO)

$0 per month Overall Plan Rating Star Rating Enroll Now 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.
Request a Call

Benefits at a Glance

Medicare PPO BlueSM SaverRx

Monthly Plan Premium Glossary

$0

Plan Information

In-Network

Out-of-Network

Medical

Doctor Office Visits

$25 copay per visit

$25 copay per visit

Specialist Office Visits

$45 copay per visit

$45 copay per visit

Medicare Preventive Services

$0 copay per visit

$0 copay per visit

Annual Medical Out-of-Pocket Maximum

In-network: $6,700 for Medicare-covered services
Combined in and out-of-network: $6,700 for Medicare-covered services

Inpatient Care Glossary

Days 1—5: $325 copay per day

Days 1—5: $325 copay per day

Outpatient Services Glossary / Surgery

$300 copay per visit

$300 copay per visit

Diagnostic Procedures, Tests and Lab Services

$30 copay per day for lab, X-rays, and other diagnostic tests; $300 copay per day for certain high-tech imaging

$30 copay per day for lab, X-rays, and other diagnostic tests; $300 copay per day for certain high-tech imaging

Emergency Care

$65 copay per visit

$65 copay per visit

Other Preventive Services

Preventive Dental

$45 copay per visit

Annual Routine Vision Exam

No coverage

Eyeglasses Benefit

No coverage

Annual Routine Hearing Exam

No coverage

Hearing Aid Benefit

No coverage

Annual Fitness Benefit

Up to $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 for Tiers 1 and 2; $310 for Tiers 3, 4, and 5

Initial Coverage Glossary

30-day retail

90-day mail order

Tier 1: Preferred Generic

$6 copay

$6 copay

Tier 2: Non-Preferred Generic

$12 copay

$24 copay

Tier 3: Preferred Brand

$45 copay

$90 copay

Tier 4: Non-Preferred Brand

$95 copay

$190 copay

Tier 5: Specialty Drugs

25% of the cost

25% of the cost

Coverage Gap Glossary

After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. For covered generics, you pay 72% 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 Glossary

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:
$2.55 copay for generics or brand drugs treated like generic drugs
$6.35 copay for all other drugs; or
5% of the cost

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

  • Prevention and wellness programs

  • Worldwide coverage for emergency care

Medicare PPO Blue SaverRx 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 SaverRx 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, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, 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 provider.bcbs.com to find a Blue Medicare Advantage PPO provider.

Summary of Benefits and Evidence of Coverage