2021 Medicare PPO Blue SaverRx
Costs & Benefits
Understand Plan Features
Plan Information
Medical |
In-Network |
Out-of-Network |
---|---|---|
Doctor Visits |
$10 copay per office or telehealth visit |
$25 copay per visit |
Specialist Visits |
$45 copay per office or telehealth visit |
$55 copay per visit |
Medicare Preventive Services |
$0 copay per visit |
$0 copay per visit |
Annual Medical Out-of-Pocket Maximum |
|
|
Inpatient Care |
Days 1-5: $390 copay per day |
Days 1-5: $440 copay per day |
Outpatient Surgery |
$325 copay per visit |
45% of the costs |
Diagnostic Procedures, Tests, and Lab Services |
|
|
Emergency Care |
$90 copay per visit |
$90 copay per visit |
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However, you can choose a Medicare Supplement and Prescription Drug plan.
Other Preventive Services |
In-Network | Out-of-Network |
---|---|---|
Preventive Dental (maximum of two visits each calendar year) |
$0 copay per visit, twice each calendar year |
$60 copay per visit, twice each calendar year |
Annual Routine Vision Exam (maximum of one exam every 12 months) |
$0 copay per annual exam with an EyeMed provider |
$45 copay per annual 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 |
$0 copay |
Annual Routine Hearing Exam (maximum one exam per 12 months) |
$0 copay for annual exam with a TruHearing provider |
$45 copay per annual exam |
Hearing Aid Benefit |
$699 copay or $999 copay for hearing aids (one per ear per year) from a TruHearing provider |
No coverage |
Annual Fitness Benefit |
Up to $150 toward fitness club membership or exercise class fees per year |
|
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, 2 and 6 | $0 |
Tiers 3, 4, and 5 |
$405 |
Initial Coverage |
Preferred Cost-Sharing Pharmacies |
Standard Cost-Sharing Pharmacies |
Express Scripts Mail Service |
---|---|---|---|
Tier 1: Preferred Generic |
$2 copay |
$10 copay |
$2 copay |
Tier 2: Generic |
$10 copay |
$16 copay |
$20 copay |
Tier 3: Preferred Brand |
$42 copay |
$47 copay |
$84 copay |
Tier 4: Non-Preferred Brand |
$95 copay |
$100 copay |
$190 copay |
Tier 5: Specialty Drugs |
25% of the cost |
25% of the cost |
25% of the cost |
Tier 6: Select Care | $0 copay | $5 copay | $0 copay |
Coverage Gap |
After your total yearly drug costs reach $4,130, 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). |
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Catastrophic Coverage |
After your yearly out-of-pocket drug costs reach $6,550 you pay the greater of:
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Additional Benefits
As a Medicare PPO Blue SaverRx 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
Prescription Drug Coverage
Medicare PPO Blue SaverRx 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 SaverRx 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, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, 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, 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) 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
Compare 2021 Medicare Plans
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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.