2023 Medicare HMO Blue SaverRx
Costs & Benefits
Understand Plan Features
Plan Information
Medical
|
Cost
|
---|---|
Doctor Visits |
$10 copay per office or telehealth visit |
Specialist Visits |
$45 copay per office or telehealth visit |
Medicare Preventive Services |
$0 copay per visit |
Annual Medical Out-of-Pocket Maximum |
$5,600 for Medicare-covered services |
Inpatient Care |
Days 1-5: $390 copay per day |
Outpatient Surgery |
$325 copay per visit |
Diagnostic Procedures, Tests, and Lab Services |
$10 copay per day for labs and other diagnostic tests; $310 copay per day per category of test for certain high-tech imaging; $60 copay for therapeutic radiological services |
X-rays |
$10 copay per day |
Emergency Care |
$90 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.
Additional Coverage and Benefits
|
Cost
|
---|---|
Preventive Dental |
$0 copay per visit, routine cleanings and exams 3 times per a 12-month period |
Comprehensive Dental |
|
Over-The-Counter (OTC) |
Up to $65 per quarter toward over-the-counter health & wellness products. There is no carry-over between quarters |
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 per year from 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 |
$300 |
|
Preferred Cost-Sharing Pharmacies
Amount for 30-day supply
|
Standard Cost-Sharing Pharmacies
Amount for 30-day supply
|
CVS Caremark Mail Service
Amount for 90-day supply
|
---|---|---|---|
Tier 1: Preferred Generic |
$0 copay |
$8 copay |
$0 copay |
Tier 2: Generic |
$8 copay |
$20 copay |
$16 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 |
28% of the cost |
28% 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:
|
Additional Benefits
As a Medicare HMO Blue SaverRx plan member, you get additional benefits beyond Original Medicare, such as:
- Coverage for routine hearing exams and vision care
- Allowances toward eyewear and hearing aids
- Routine preventive dental care
- Prevention and wellness programs
- NEW for 2023 - Learn to Live Online Cognitive Behavioral Therapy
- Worldwide coverage for emergency care
Prescription Drug Coverage
Medicare HMO Blue SaverRx also offers Medicare Part D prescription drug coverage—making it easy for you to get your medical and prescription benefits from one plan.
Summary of Benefits and Evidence of Coverage
- 2023 Medicare HMO Blue SaverRx (HMO) Summary of Benefits (Updated 10/01/2022)
- 2023 Medicare HMO Blue SaverRx (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.