Medicare PPO BlueSM ValueRx (PPO)

Overall Plan Rating1Overall Plan Rating

As a member of PPO Blue ValueRx, you have access to both in-network and out-of-network doctors, hospitals, and other providers with no referral requirements. Your costs for in- and out-of-network services will be the same in most cases. However, for some services you may have higher out-of-pocket costs if you go outside the network.

Visit the Enroll section for information on how to enroll online, by mail, or via phone or fax. Medicare beneficiaries may also enroll in this plan through the CMS Medicare Online Enrollment Center.

For benefit details, click on the sections listed below.

$792

per month

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Benefits at a Glance

Medicare PPO BlueSM ValueRx

Monthly Plan Premium

$792

Plan Information

In-Network

Out-of-Network

Medical

Doctor Office Visits

$20 copay per visit

$20 copay per visit

Specialist Office Visits

$40 copay per visit

$40 copay per visit

Medicare Preventive Services

$0 copay per visit

$0 copay per visit

Annual Medical Out-of-Pocket Maximum

$4,900 for Medicare-covered services In-Network and Out-Of-Network combined.

Days 1-5: $250 copay per day

Days 1-5: $250 copay per day

$225 copay per visit

$225 copay per visit

Diagnostic Procedures, Tests, X-rays, and Lab Services

$20 copay per day for lab, X-rays, and other diagnostic tests; $250 copay per day for certain high-tech imaging

$20 copay per day for lab, X-rays, and other diagnostic tests; $250 copay per day for certain high-tech imaging

Emergency Care

$75 copay per visit

$75 copay per visit

Other Preventive Services

Preventive Dental

$40 copay per visit, once every six months

Annual Routine Vision Exam

$40 copay for one routine test per year

Eyeglasses Benefit

$150 limit for routine eyewear every two years

Annual Routine Hearing Exam

$20-$40 copay for one routine test per year

Hearing Aid Benefit

Not covered

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 per year

Prescription Drug Coverage

Cost

Annual Deductible

  • $0 for Tiers 1 and 2;

  • $320 for Tiers 3, 4, and 5

30-day retail

90-day mail order

Tier 1: Preferred Generic

$4 copay

$4 copay

Tier 2: Generic

$8 copay

$16 copay

Tier 3: Preferred Brand

$45 copay

$90 copay

Tier 4: Non-Preferred Brand

$95 copay

$190 copay

Tier 5: Specialty Drugs

26% of the cost

26% of the cost

After your total yearly drug costs reach $3,700, you receive limited coverage by the plan on certain drugs. For covered generics, you pay 51% of the plan's costs. For covered brand drugs, you pay no more than 40% of the plan's costs (excluding dispensing fees).

After your yearly out-of-pocket drug costs reach $4,950, you pay the greater of:

  • $3.30 copay for generics or brand drugs treated like generic drugs and a $8.25 copay for all other drugs; or

  • 5% of the cost

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

  • Coverage for routine hearing exams, vision care, and preventive dental

  • 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, Illinois, 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 to find a Blue Medicare Advantage PPO provider.

Summary of Benefits and Evidence of Coverage

Access to Doctors and Hospitals with Medicare PPO Blue ValueRx

Medicare PPO Blue ValueRx uses a network of doctors, specialists, and hospitals. You can choose any doctor who is part of our network to be your provider of choice. Our list of network providers shows you the number and type of providers in our network. Your provider of choice can help you coordinate your care, however, you may also see any Medicare-participating providers outside the network. Your cost-share for in- and out-of-network covered services is the same in most cases.

Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Blue Shield of Massachusetts Medicare PPO Blue members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Member Service number on your ID Card or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Is my doctor in the network?

If you already have a primary care provider A doctor who is trained to give you basic care. In many Medicare managed care plans, you must see your primary care doctor before you see any other health care provider. and want to learn whether he or she is already a part of our network, just visit Find a Doctor or call 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET.

  • October 1-February 14: 7 days a week

  • February 15-September 30: Monday through Friday

If you would like a Provider Directory mailed to you, you may call Member Service at the number above.

Looking for a new physician?

You can choose a doctor from our list of participating providers. Our network of physicians is subject to change, but you can keep up-to-date with the most complete list of current network physicians by:

  • using our Find a Doctor feature or

  • calling Member Service at 1-800-200-4255 (TTY: 711) from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, or October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. You may also request to have the Provider Directory mailed to you.

Prescription Drug Coverage
Medicare Advantage Pharmacy Network & Formulary

Our Pharmacy and Therapeutics Committee frequently reviews the list of covered medications for safety and effectiveness. To learn more about this process, our formulary, or why changes to the formulary might be made, visit this section.

Prescription Drug Coverage Summary

Prescription Drug Coverage

Cost

  • $0 for Tiers 1 and 2;

  • $320 for Tiers 3, 4, and 5

30-day retail

90-day mail order

Tier 1: Preferred Generic

$4 copay

$4 copay

Tier 2: Generic

$8 copay

$16 copay

Tier 3: Preferred Brand

$45 copay

$90 copay

Tier 4: Non-Preferred Brand

$95 copay

$190 copay

Tier 5: Specialty Drugs

26% of the cost

26% of the cost

After your total yearly drug costs reach $3,700, you receive limited coverage by the plan on certain drugs. For covered generics, you pay 51% of the plan's costs. For covered brand drugs, you pay no more than 40% of the plan's costs (excluding dispensing fees).

After your yearly out-of-pocket drug costs reach $4,950, you pay the greater of:

  • $3.30 copay for generics or brand drugs treated like generic drugs and a $8.25 copay for all other drugs; or

  • 5% of the cost

Pharmacy Directory

There are over 1,200 pharmacies in our Massachusetts network and over 61,900 pharmacies in our nationwide network. We contract with pharmacies that equal or exceed regulatory requirements for pharmacy access in your area. To find a pharmacy near you, use our online pharmacy search tool or download the pharmacy directory below.

(The pharmacies listed in this network may differ from those in the Blue MedicareRxSM (PDP) network. Please call Member Service at 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET as follows: from October 1 through February 14, seven days a week, and from February 15 through September 30, Monday through Friday, or visit Blue MedicareRx (PDP) for more information.)

We may periodically make changes to the formulary A formulary is a list of covered drugs under a Medicare Advantage Part D Plan. The list includes both brand-name and generic drugs. In some Medicare health plans, doctors must order or use only drugs listed on the health plan's formulary. (covered drug list). If we remove a medication from the formulary, affected members will be notified in writing before the change is made.

View Medicare Advantage Network and Formulary

You are eligible to enroll if you meet all of the following requirements:
  • You are eligible for Medicare Part A and enrolled in Part B.

  • You permanently live in Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, or Worcester counties in Massachusetts.

  • You do not currently have end-stage renal disease (ESRD). You may join this plan if you previously had ESRD but have recovered normal kidney function and no longer need regular dialysis. You may also join if you’ve had a successful kidney transplant or are currently a member of Blue Cross Blue Shield of Massachusetts. In addition, if you were a member of a Medicare Advantage plan that ended its services after December 31, 1998, and you currently have ESRD, you may still join the plan. There may be additional requirements. Please contact the plan for details.

Get Healthy Discounts & Programs

With Medicare PPO Blue ValueRX, you get access to information, support, tools, and discounts to help you be your healthiest.

Program/Discount

What It Offers

Get up to $150 per calendar year toward a qualified health club.

Get up to $150 per calendar year when you join a qualified Weight Watchers®'' or a hospital-based weight loss program.

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1

Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. Star Ratings can be found at www.medicare.gov.

2

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

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.