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BlueMedicare Value (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for BlueMedicare Value (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on BlueMedicare Value (PPO) in 2026, please refer to our full plan details page.
BlueMedicare Value (PPO) is a PPO plan offered by Guidewell Mutual Holding Corporation available for enrollment in 2025 to people living in Lake, Marion, & Sumter counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that BlueMedicare Value (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 BlueMedicare Value (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 BlueMedicare Value (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $615.00 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 $10100.00 (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 $10100.00 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 BlueMedicare Value (PPO) plan features an annual drug deductible of $615. Beneficiaries enjoy no copay for Tier 1 preferred generic, Tier 2 generic, and Tier 6 select care drugs when using standard pharmacies or standard mail order services. This coverage applies to both 1-month and 3-month supplies, helping you save on common medications. For higher-tier medications, cost sharing is determined by a percentage of the drug cost during the initial coverage phase. Tier 3 preferred brand drugs require 21% coinsurance, while Tier 4 non-preferred drugs carry a 30% coinsurance for both 1-month and 3-month supplies. Specialty drugs in Tier 5 have a 25% coinsurance for a 1-month supply through standard pharmacy or standard mail order.
Additional Benefits
The BlueMedicare Value (PPO) plan provides medical coverage with no copay and no coinsurance for primary care visits and covered preventive services. Specialist office visits feature a low copay ranging from $0 to $40, while emergency room services require a $130 copay that is waived upon hospital admission. For hospital stays, inpatient acute care requires a $320 daily copay for the first seven days, and outpatient hospital services range from no copay to a $275 copay, both with no coinsurance. Supplemental benefits include routine dental, vision, and hearing exams with no copay and no coinsurance, along with a $200 annual allowance for eyewear and a $35 quarterly allowance for over-the-counter items. Additionally, there is no copay or coinsurance for home health services or the first 20 days of a skilled nursing facility stay. Durable medical equipment and dialysis services are also covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are covered by BlueMedicare Value (PPO) with no coinsurance, requiring a $320 daily copay for days 1 through 7 of an acute stay and a $350 daily copay for days 1 through 6 of a psychiatric stay. Prior authorization is required, there is no copay for subsequent covered days, and specific sub-services such as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
BlueMedicare Value (PPO) covers outpatient hospital services with a $0 to $275 copay and observation services with a $130 copay per stay, both with no coinsurance. Patients will pay a $225 copay for ambulatory surgical center services and a $30 to $40 copay for outpatient substance abuse sessions, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
BlueMedicare Value (PPO) covers partial hospitalization services with a $50.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
BlueMedicare Value (PPO) covers ground ambulance services with a copay of $0 to $410 and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Prior authorization is required for ambulance services, and transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services are covered under the BlueMedicare Value (PPO) plan with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 48 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency and urgent care are partially covered up to a $25,000 maximum with a $130 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
BlueMedicare Value (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $0 to $40 copay and no coinsurance. Additional covered benefits like physical, occupational, and speech therapy, mental health services, and telehealth feature copays ranging from $0 to $50 with no coinsurance, though some require prior authorization. Podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by BlueMedicare Value (PPO) with no copay and no coinsurance for covered services, which include kidney disease education, glaucoma screenings, and memory fitness. However, several sub-services are not covered, including annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
BlueMedicare Value (PPO) covers hearing services, including annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $350.00 to $1,825.00 for up to two hearing aids per year, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
BlueMedicare Value (PPO) provides partially covered vision services with no deductibles, including one annual routine eye exam with no copay and no coinsurance, while other eye exam services are not covered. Covered eyewear, including contact lenses, eyeglasses, and upgrades, also features no copay and no coinsurance up to a $200 annual combined maximum limit.
Dental Services See details
Dental services are partially covered by BlueMedicare Value (PPO), with Medicare-covered dental requiring a $40 copay and no coinsurance, while covered preventive care, fillings, dentures, and oral surgery are offered with no copay and no coinsurance. Sub-services that are not covered under this plan include other diagnostic services, endodontics, periodontics, implants, fixed prosthodontics, orthodontics, maxillofacial prosthetics, and adjunctive general services.
Home Infusion bundled Services See details
BlueMedicare Value (PPO) covers home infusion bundled services with prior authorization, featuring 0% to 20% coinsurance for covered Part B chemotherapy, radiation, and other drugs. Part B insulin is covered with a $35 copay and 0% to 20% coinsurance, while other Part B drugs require no copay.
Dialysis Services See details
Dialysis Services are covered under the BlueMedicare Value (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
BlueMedicare Value (PPO) covers durable medical equipment and prosthetics with no copay and a 20% coinsurance. Diabetic equipment, supplies, and therapeutic shoes or inserts are also covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under BlueMedicare Value (PPO), with prior authorization required for these services. Diagnostic services feature no coinsurance, offering lab services with no copay and diagnostic procedures or tests with a copay ranging from $0 to $75. Radiological services include outpatient X-rays for a $15 copay, diagnostic radiology starting at no copay, and therapeutic radiology with a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the BlueMedicare Value (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under BlueMedicare Value (PPO) with no coinsurance and require prior authorization, meaning some services are covered. However, standard cardiac rehabilitation (with a $35 copay), intensive cardiac rehabilitation (with a $50 copay), pulmonary rehabilitation (with a $15 copay), and supervised exercise therapy for peripheral artery disease (with a $25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
BlueMedicare Value (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a daily copay of $218 for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
BlueMedicare Value (PPO) partially covers other services, providing over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $35 every three months. Acupuncture, meal benefits, and other additional services are not covered.
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