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Medicare PPO Blue PlusRx (PPO)

H2230 - 002 - 0
3.5 out of 5 stars (3.5 / 5)

Medicare PPO Blue PlusRx (PPO) is a Medicare Advantage Plan by Blue Cross Blue Shield of Massachusetts.

This page features plan details for 2025 Medicare PPO Blue PlusRx (PPO) H2230 – 002 – 0 available in Massachusetts except Berkshire Dukes and Nantucket.

Locations

Medicare PPO Blue PlusRx (PPO) is offered in the following locations.

Barnstable County, Massachusetts
Bristol County, Massachusetts
Essex County, Massachusetts

Click to see more locations

Plan Overview

Medicare PPO Blue PlusRx (PPO) offers the following coverage and cost-sharing.

Insurer:Blue Cross Blue Shield of Massachusetts
Health Plan Deductible:$0
MOOP:$5,100 In and Out-of-network
$3,800 In-network
Drugs Covered:Yes

Ready to sign up for Medicare PPO Blue PlusRx (PPO) ?

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 PPO Blue PlusRx (PPO) has a monthly premium of $250.00. 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 $179.40 $70.60 $ $
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 PPO Blue PlusRx (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $200.00
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 DLIS Full
$70.60$49.00

Initial Coverage Phase

After you pay your $200.00 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.

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 PPO Blue PlusRx (PPO) 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
    • Out-of-Network: No Coins – 45.00 Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – 45.00 Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – 45.00 Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $150 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 20% coinsurance (Authorization Required)
    • In-Network: $10 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0-10 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-10 copay (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $45 copay per visit
  • Specialist
    • Out-of-Network: $45 copay per visit (Authorization Required)
  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $0-35 copay per visit (Authorization Required)

Emergency care/Urgent care

  • Emergency
    • $140 copay per visit (always covered)
  • Urgent care
    • $0-45 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $0-35 copay
    • Out-of-Network: $45 copay
  • Routine foot care
    • Not covered

Ground ambulance

    • In-Network: $200 copay
    • Out-of-Network: $200 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • Out-of-Network: $45 copay
  • Hearing aids
    • In-Network: $699-999 copay (Limits Apply)
    • Out-of-Network: $699-999 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $0-35 copay
  • Fitting/evaluation
    • In-Network: $0 copay
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $45 copay

Inpatient hospital coverage

    • Out-of-Network: 20% per stay (Authorization Required)
    • In-Network: $125 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)

    • $5,100 In and Out-of-network
      $3,800 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: $0 copay (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 20% coinsurance per item
  • Diabetes supplies
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 10% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 10% coinsurance per item

Medicare Part B drugs

  • Other Part B drugs
    • In-Network: 0-10% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: 10% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 10% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-10% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit
    • In-Network: $25 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $125 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $25 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $0-25 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $25 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: 20% per stay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 20% coinsurance (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 20% coinsurance per visit (Authorization Required)
    • In-Network: $150 copay per visit (Authorization Required)

Preventive care

    • Out-of-Network: $45 copay or 20% coinsurance (Authorization Required)
    • In-Network: $0 copay (Authorization Required)

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $15 copay (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: 20% coinsurance (Authorization Required)
    • In-Network: $15 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 20% coinsurance (Authorization Required)

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $100 per day for days 21 through 44
      $0 per day for days 45 through 100 (Authorization Required)
    • Out-of-Network: 20% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $45 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Not covered
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered

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

    • Covered

Ready to sign up for Medicare PPO Blue PlusRx (PPO) ?

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

Need more information on Medicare PPO Blue PlusRx (PPO)? See 2025 Medicare PPO Blue PlusRx (PPO) at MedicareAdvantageRX.com.

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