2023 Medicare PPO Blue ValueRx
Costs & Benefits
Understand Plan Features
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 |
|
|
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 |
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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.
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 |
Standard Cost-Sharing Pharmacies |
CVS Caremark Mail Service |
---|---|---|---|
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:
|
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
- 2023 Medicare PPO Blue ValueRx (PPO) Summary of Benefits (Updated 10/01/2022)
- 2023 Medicare PPO Blue ValueRx (PPO) 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.