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Medicare PPO Blue PlusRx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare PPO Blue PlusRx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare PPO Blue PlusRx (PPO) in 2025, please refer to our full plan details page.
Medicare PPO Blue PlusRx (PPO) is a PPO plan offered by Blue Cross and Blue Shield of Massachusetts, Inc. available for enrollment in 2025 to people living in Massachusetts except Berkshire Dukes and Nantucket. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Medicare PPO Blue PlusRx (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Medicare PPO Blue PlusRx (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Medicare PPO Blue PlusRx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $250.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $200.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $5100.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $5100.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Medicare PPO Blue PlusRx (PPO) plan has a $200 deductible for prescription drugs. In the initial coverage phase, after meeting the deductible, you'll pay a copay for your prescriptions depending on the drug tier and pharmacy. For example, preferred generic drugs have a $5 copay at preferred pharmacies and a $10 copay at standard pharmacies, while standard generic drugs have a $42 copay at preferred pharmacies and a $47 copay at standard pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Medicare PPO Blue PlusRx (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay of $125 per day for the first five days, with no copay thereafter. Outpatient services, including hospital and ambulatory surgical center services, have copays ranging from $100 to $150. The plan also covers primary care, preventive services, hearing, vision, dental, and home infusion services with varying copays or coinsurance. Emergency services have a copay of $140, while ambulance services have a $200 copay. Additionally, the plan covers skilled nursing facility services with no copay for the first 20 days, and dialysis services with 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $125 per day for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute, and a copay of $125 per day for days 1-5 and no copay for days 6-90 for Inpatient Hospital Psychiatric services. Additional days for both are covered. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered under the Medicare PPO Blue PlusRx (PPO) plan. Outpatient Hospital Services have a $150 copay, and Ambulatory Surgical Center (ASC) Services have a $100 copay. Outpatient Substance Abuse Services, including both individual and group sessions, have a $25 copay. Outpatient Blood Services are also covered, with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medicare PPO Blue PlusRx (PPO) plan, with a $200 copay for both ground and air ambulance services. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services under the Medicare PPO Blue PlusRx (PPO) plan include a $140 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $45, with no coinsurance. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, each have a $75 copay, with no coinsurance.
Primary Care See details
The Medicare PPO Blue PlusRx (PPO) plan covers Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services has a $20 copay for routine care, while Occupational Therapy Services has a $15 copay. Physician Specialist Services and Additional Telehealth Benefits have copays ranging from $0 to $35. Individual Sessions for Mental Health and Psychiatric Services have copays ranging from $0 to $25, and Group Sessions for Mental Health and Psychiatric Services have a $25 copay. Physical Therapy and Speech-Language Pathology Services have a $15 copay. Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered zero dollar preventive services with prior authorization, annual physical exams, health education, wigs for hair loss related to chemotherapy (up to $500 per year), weight management programs (up to $150 per year), Fitness Benefit (Memory Fitness, up to $250 per year), Enhanced Disease Management, Remote Access Technologies, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services are covered, including routine hearing exams with no copay for one visit per year, and fitting/evaluation for hearing aids. Prescription hearing aids are covered, with a copay between $699 and $999 for up to two visits per year, but prescription hearing aids for the inner ear, outer ear, and over the ear, as well as OTC hearing aids, are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay of $0-$35, routine eye exams once per year, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $200 every two years. Upgrades are not covered.
Dental Services See details
Dental Services are covered under the Medicare PPO Blue PlusRx (PPO) plan, including oral exams, dental x-rays, and prophylaxis (cleaning) with a $35 copay. Fluoride treatment, orthodontic services, and other dental services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0-10%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0-10%.
Dialysis Services See details
Dialysis Services are covered under the Medicare PPO Blue PlusRx (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Medicare PPO Blue PlusRx (PPO) plan. Durable Medical Equipment has a 10% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 10% coinsurance, and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Medicare PPO Blue PlusRx (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $10, Lab Services have no copay, Diagnostic Radiological Services have a copay of at most $150, and Outpatient X-Ray Services have a $10 copay, while Therapeutic Radiological Services are not covered.
Home Health Services See details
Home Health Services are covered by the Medicare PPO Blue PlusRx (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Medicare PPO Blue PlusRx (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Medicare PPO Blue PlusRx (PPO) plan, but require prior authorization. For days 1-20, there is no copay, for days 21-44 there is a $100 copay, and for days 45-100, there is no copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are covered, but acupuncture, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. The plan provides a meal benefit for a chronic illness.
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