Medicare PPO Blue SaverRx (PPO)


Medicare Plan Details

2020 Plan
Monthly Premium
(select county for price)

 

by Blue Cross Blue Shield of Massachusetts
Additional Coverage
Dental
Overall Government Star Rating
 4.5
out of 5 stars

State: Massachusetts

Select your county to view the price for this plan

 


Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$6,700 In and Out-of-network
$6,700 In-network
No
No
No
Yes

Medical Benefits

Doctor Services

In-network: $25 per visit
Out-of-network: $25-45 per visit
In-network: $45 per visit
Out-of-network: $45 per visit

Tests, labs, & imaging

In-network: $10
Out-of-network: $10
In-network: $10
Out-of-network: $10
In-network: $325
Out-of-network: $325
In-network: $10
Out-of-network: $10
$90 per visit (always covered)
$25-45 per visit (always covered)

Hospital Services

In-network: $350 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Out-of-network: $350 per day for days 1 through 5
$0 per day for days 6 through 90
In-network: $300 per visit
Out-of-network: $300 per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$160 per day for days 21 through 44
$0 per day for days 45 through 100
Out-of-network: 20% per stay

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $250
Out-of-network: $250

Therapy services

In-network: $40
Out-of-network: $40
In-network: $40
Out-of-network: $40

Mental health services

In-network: $40
Out-of-network: $40
In-network: $40
Out-of-network: $40
In-network: $40
Out-of-network: $40
In-network: $40
Out-of-network: $40

Opioid treatment services

Covered

Other services

In-network: 20% per item
Out-of-network: 20% per item
In-network: 20% per item
Out-of-network: 20% per item
In-network: $0 copay
Out-of-network: $0 copay

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$10.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$3.60 copay or 5% (whichever costs more)

Brand-name drugs :
$8.95 copay or 5% (whichever costs more)

Generic$16.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug
Specialty Tier25%

Part B Drugs

In-network: 20%
Out-of-network: 20%
In-network: 20%
Out-of-network: 20%

Extra Benefits

Hearing

In-network: $25-45
Out-of-network: $25-45
Not covered
Not covered
Not covered
Not covered

Preventive Dental

Covered under office visit
Covered under office visit
Not covered
Covered under office visit

Comprehensive dental

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Vision

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Not covered
Not covered
Not covered
Not covered
Limited coverage
Not covered
 4
 4
 4
 3
 4
 5
 4.5
 4
 5
 3
 5

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