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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

$20 copay per visit

Specialist Visits

$40 copay per office or telehealth visit

$50 copay per visit

Medicare Preventive Services

$0 copay per visit

$0 copay per visit

Annual Medical Out-of-Pocket Maximum

$4,900 for Medicare-covered services In-Network and Out-Of-Network combined.
Inpatient Care

Days 1-5: $325 copay per day

Days 1-5: $350 copay per day
Outpatient Surgery

$250 copay per visit

40% of the cost

Diagnostic Procedures, Tests, and Lab Services

$0 for lab and other diagnostic tests

$10 per day for X-rays; $250 copay per day per category of test for certain high-tech imaging

$0 copay therapeutic radiology

40% of the costs for lab, X-rays, and other diagnostic tests; $325 copay per day for certain high-tech imaging

40% of the costs for therapeutic radiology

Emergency Care

$90 copay per visit

$90 copay per visit

 

Other Preventive Services

In-Network

Out-of-Network

Preventive Dental

(routine cleanings and exams 3 times per a 12-month period)

$0 copay

$50 copay
Comprehensive Dental
  • You pay 50% coinsurance for covered comprehensive dental services.
  • Comprehensive dental services include but not limited to: Fillings, extractions, periodontal scaling, crowns, root canal therapy, bridges and repair. Frequency limits apply.
  • There is a $1000 calendar year maximum for preventive and comprehensive dental services after which you pay all costs.

Annual Routine Vision Exam

(maximum of one exam every 12 months)

$0 copay for one routine exam with an EyeMed provider

$45 copay for 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 of one exam per 12-month period)

$0 copay for one routine exam with a TruHearing provider

$45 copay for annual exam

Hearing Aid Benefit

$699 copay or $999 copay per aid (one per ear per year) from a TruHearing provider

Not covered

Annual Fitness Benefit

Up to $150 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 through 5 There is no deductible for this plan

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

$8 copay

$0 copay

Tier 2: Generic

$6 copay

$12 copay

$12 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:

  • $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

Additional Benefits

As a Medicare PPO Blue ValueRx 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 and NEW coverage for comprehensive dental services
  • 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 ValueRx 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 ValueRx 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, DC, 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) 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.