2023 Medicare HMO Blue PlusRx
Costs & Benefits
Understand Plan Features
Plan Information
Medical | Cost |
---|---|
Doctor Visits |
$0 copay per office or telehealth visit |
Specialist Visits |
$30 copay per office or telehealth visit |
Medicare Preventive Services |
$0 copay per visit |
Annual Medical Out-of-Pocket Maximum |
$3,400 for Medicare-covered services |
Inpatient Care |
Days 1-5: $125 copay per day |
Outpatient Surgery |
$150 copay per visit |
Diagnostic Procedures, Tests, and Lab Services |
$0 copay per day for labs, and other diagnostic tests; $5 copay per day for x-rays; $150 copay per day per category of test for certain high-tech imaging, $0 copay for therapeutic radiological services |
Emergency Care |
$75 copay per visit |
- -
We could not find Medicare Advantage Plans available in your area or Please enter a valid zip code.
However, you can choose a Medicare Supplement and Prescription Drug plan.
Other Preventive Services |
Cost |
---|---|
Preventive Dental |
$0 copay per visit, twice each calendar year |
Annual Routine Vision Exam |
$0 copay for one routine exam every 12 months with an EyeMed provider |
Eyeglasses Benefit |
$200 limit for routine eyewear every 24 months from an EyeMed provider |
Annual Physical Exam |
$0 copay |
Annual Routine Hearing Exam |
$0 copay for one routine exam every 12 months with a TruHearing provider |
Hearing Aid Benefit |
$699 copay or $999 copay per hearing aid (one per ear per year) from a TruHearing provider |
Annual Fitness Benefit |
Up to $250 toward fitness club membership, exercise class fees, online class fees, fitness equipment, and pool-only facilities |
Weight Loss Benefit |
Up to $150 toward fees paid for qualified weight loss programs per year |
To confirm your eligibility and schedule a routine vision or hearing appointment please contact:
EyeMed: 1-866-490-7291 (TTY: 711)
October 1 through March 31: 8:00 a.m. - 11:00 p.m. ET., 7 days a week
April 1 through September 30: 8:00 a.m. - 11:00 p.m. ET., Monday through Saturday;
11:00 a.m. - 8:00 p.m, Sunday.
TruHearing: 1-844-811-3762 (TTY: 711)
8:00 a.m. - 9:00 p.m. ET, Monday through Friday.
Prescription Drug Coverage
Prescription Drug Annual Deductible |
Cost |
---|---|
Tiers 1 and 2 | $0 |
Tiers 3, 4, and 5 |
$200 |
Preferred Cost-Sharing Pharmacies |
Standard Cost-Sharing Pharmacies |
CVS Caremark Mail Service |
|
---|---|---|---|
Tier 1: Preferred Generic |
$0 copay |
$6 copay |
$0 copay |
Tier 2: Generic |
$5 copay |
$10 copay |
$10 copay |
Tier 3: Preferred Brand |
$42 copay |
$47 copay |
$84 copay |
Tier 4: Non-Preferred Drug |
$95 copay |
$100 copay |
$190 copay |
Tier 5: Specialty Drugs |
29% of the cost |
29% of the cost |
Not available at 90-day supply |
Coverage Gap |
After your total yearly drug costs reach $4,660, you receive limited coverage by the plan on certain drugs. For covered generics, you pay 25% of the plan's costs. For covered brand drugs, you pay no more than 25% of the plan's costs (excluding dispensing fees). |
||
Catastrophic Coverage |
After your yearly out-of-pocket drug costs reach $7,400 you pay the greater of:
|
CVS Caremark, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts.
Additional Benefits
As a Medicare HMO 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
- NEW for 2023 - Learn to Live Online Cognitive Behavioral Therapy
- Worldwide coverage for emergency care
Summary of Benefits and Evidence of Coverage
- 2023 Medicare HMO Blue PlusRx (HMO) Summary of Benefits (Updated 10/01/2022)
- 2023 Medicare HMO Blue PlusRx (HMO) Evidence of Coverage (Updated 10/01/2022)
Compare 2023 Medicare Plans
No Plans Found
We could not find Medicare plans available in your area. Please make sure the Massachusetts ZIP code you entered is correct.
Other Medicare Plans
- Your monthly premium will be different if you qualify for Extra Help from Medicare.
- This information is not a complete description of benefits. Call 1-800-200-4255 (TTY: 711) for more information.
- Every year, Medicare evaluates plans based on a 5-star rating system.