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Medicare HMO Blue ValueRx (HMO)

H2261 - 022 - 2

(3.5 / 5)

Medicare HMO Blue ValueRx (HMO) is a Medicare Advantage Plan by Blue Cross Blue Shield of Massachusetts.

This page features plan details for 2025 Medicare HMO Blue ValueRx (HMO) H2261 – 022 – 2 available in Massachusetts except Berkshire, Dukes, Nantucket.

Locations

Medicare HMO Blue ValueRx (HMO) is offered in the following locations.

Massachusetts

Worcester County, Massachusetts

Click to see more locations

Plan Overview

Medicare HMO Blue ValueRx (HMO) offers the following coverage and cost-sharing.

Insurer:	Blue Cross Blue Shield of Massachusetts
Health Plan Deductible:	$0
MOOP:	$3,750 In-network
Drugs Covered:	Yes

Ready to sign up for Medicare HMO Blue ValueRx (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Medicare HMO Blue ValueRx (HMO) has a monthly premium of $42.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$42.00	$0.00	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Medicare HMO Blue ValueRx (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$320.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $320.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$8.00 Copay
2) Generic	$6.00 Copay	$12.00 Copay	$6.00 Copay
3) Preferred Brand	$42.00 Copay	$47.00 Copay	$42.00 Copay
4) Non-Preferred Drug	$95.00 Copay	$100.00 Copay	$95.00 Copay
5) Specialty Tier	27.00% Coinsurance	27.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$16.00 Copay
2) Generic	$12.00 Copay	$24.00 Copay	$12.00 Copay
3) Preferred Brand	$84.00 Copay	$94.00 Copay	$84.00 Copay
4) Non-Preferred Drug	$190.00 Copay	$200.00 Copay	$190.00 Copay
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$24.00 Copay
2) Generic	$18.00 Copay	$36.00 Copay	$12.00 Copay
3) Preferred Brand	$126.00 Copay	$141.00 Copay	$84.00 Copay
4) Non-Preferred Drug	$285.00 Copay	$300.00 Copay	$190.00 Copay
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Medicare HMO Blue ValueRx (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Outpatient x-rays
- $10 copay (Authorization Required)
Lab services
- $0-10 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- $250 copay (Authorization Required)
Diagnostic tests and procedures
- $0-10 copay (Authorization Required)

Doctor visits

Primary
- $10 copay per visit
Specialist
- $0-40 copay per visit (Authorization Required, Referral Required)

Emergency care/Urgent care

Emergency
- $140 copay per visit (always covered)
Urgent care
- $0-40 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $10-40 copay (Referral Required)
Routine foot care
- Not covered

Ground ambulance

- $250 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $10-40 copay
Hearing aids
- $699-999 copay (Limits Apply)
Fitting/evaluation
- $0 copay

Inpatient hospital coverage

- $330 per day for days 1 through 7
  $0 per day for days 8 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $3,750 In-network

Medical equipment/supplies

Diabetes supplies
- $0 copay (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance (Authorization Required)
Other Part B drugs
- 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient group therapy visit
- $25 copay (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- $25 copay (Authorization Required)
Inpatient hospital – psychiatric
- $275 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- $25 copay (Authorization Required)
Outpatient individual therapy visit
- $0-25 copay (Authorization Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $250 copay per visit (Authorization Required)

Preventive care

- $0 copay (Authorization Required)

Rehabilitation services

Physical therapy and speech and language therapy visit
- $20 copay (Authorization Required, Referral Required)
Occupational therapy visit
- $20 copay (Authorization Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $160 per day for days 21 through 44
  $0 per day for days 45 through 100 (Authorization Required)

Transportation

- Not covered

Vision

Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Contact lenses
- $0 copay (Limits Apply)
Upgrades
- Not covered
Eyeglass frames
- $0 copay (Limits Apply)
Eyeglass lenses
- $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered