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Medicare PPO Blue PlusRx (PPO)

$124* 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 PlusRx

Monthly Plan Premium Glossary

$124*

Plan Information

In-Network

Out-of-Network

Medical

Doctor Office Visits

$15 copay per visit

$40 copay per visit

Specialist Office Visits

$30 copay per visit

$40 copay per visit

Medicare Preventive Services

$0 copay per visit

$40 copay or 20% of the cost per visit

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 Glossary

Days 1—5: $150 copay per day
$750 annual out-of-pocket maximum

20% of the cost

Outpatient Hospital Care Glossary / Surgery

$100 copay per visit

20% of the cost

Diagnostic Procedures, Tests and Lab Services

$0 copay per day for lab; $100 copay per day for certain high-tech imaging, and $0 copay per day for X-rays and other diagnostic tests

20% of the cost

Emergency Care

$65 copay per visit

$65 copay per visit

Other Preventive Services

Preventive Dental

$30 copay per visit

$40 copay per visit

Annual Routine Vision Exam

$30 copay for 1 routine test per year

$40 copay for 1 routine test per year

Eyeglasses Benefit

$150 limit for routine eyewear every two years

Annual Routine Hearing Exam

$15—$30 copay for 1 routine test per year

$40 copay for 1 routine test per year

Hearing Aid Benefit

Up to $400 limit every 3 years

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

Initial Coverage Glossary

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

$4 copay
$8 copay
$45 copay
$95 copay
30% of the cost

$4 copay
$16 copay
$90 copay
$190 copay
30% 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 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 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 PlusRx 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) 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:

  • Call the Member Service phone line during regular business hours, or

  • Call 1-800-810-BLUE (TTY 1-800-522-1254) 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

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