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Part A Eligible:
Coverage Year:
Zip Code:

Your Information

Plan Information

Medical

In-Network

Out-of-Network

Doctor Visits

$0 copay per office or telehealth visit

$45 copay per visit

Specialist Visits

$35 copay per office or telehealth visit

$45 copay per visit

Medicare Preventive Services

$0 copay per visit

$45 copay or 20% of the cost per visit depending on the service

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

Days 1-5: $125 copay per day

20% of the cost
Outpatient Surgery

$150 copay per visit

20% of the cost

Diagnostic Procedures, Tests, and Lab Services
  • $10 copay per day for lab, X-rays, and other diagnostic tests;
  • $150 copay per day per category of test for certain high-tech imaging
  • $0 therapeutic radiology.
  • 20% of the cost for lab, X-rays, and other diagnostic tests;
  • 40% of the cost for high-tech imaging
  • 20% of the cost of therapeutic radiology.

Emergency Care

$75 copay per visit

$75 copay per visit

Other Preventive Services

In-Network

Out-of-Network

Preventive Dental

(maximum of two visits each calendar year)

$0 copay

$45 copay

Annual Routine Vision Exam

(maximum one exam every 12 months)

$0 copay for one routine exam through an EyeMed provider

$45 copay for one routine exam

Eyeglasses Benefit

(maximum of $200 every 24 months)

$200 limit for routine eyewear every 24 months with an EyeMed provider

$200 limit for routine eyewear every 24 months
Annual Physical Exam $0 copay $45 copay

Annual Hearing Exam

(maximum of one exam every 12 months)

$0 copay for one routine exam with a TruHearing provider

$45 copay for one routine exam per year

Hearing Aid Benefits 

For hearing aids, you pay $699 copayment per aid for Advanced Aids or $999 copayment per aid for Premium Aids through a TruHearing provider.

No coverage

Annual Fitness Benefit

$250 per year 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

Initial Coverage 

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

$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:

  • $4.15 copay for generics or drugs treated like generic drugs and a $10.35 copay for all other drugs; or
  • 5% of the cost

CVS Caremark, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts.

Additional Benefits

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 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 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 and territories: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, 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 711) 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

  • 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.