A non-government entity
Vermont Blue Advantage Tribute PPO (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Vermont Blue Advantage Tribute PPO (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Vermont Blue Advantage Tribute PPO (PPO) in 2025, please refer to our full plan details page.
Vermont Blue Advantage Tribute PPO (PPO) is a PPO plan offered by Blue Cross Blue Shield of Michigan Mutual Ins. Co. available for enrollment in 2025 to people living in State of Vermont. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Vermont Blue Advantage Tribute PPO (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Vermont Blue Advantage Tribute PPO (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 Vermont Blue Advantage Tribute PPO (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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $7750.00 (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 $7750.00 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:
Sign up for Vermont Blue Advantage Tribute PPO (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
Prescription drugs are not covered by Vermont Blue Advantage Tribute PPO (PPO).
Additional Benefits
The Vermont Blue Advantage Tribute PPO (PPO) plan offers comprehensive coverage with varying costs for different services. Inpatient hospital stays have a $450 copay for the first five days, with no copay for days 6-90. Outpatient services and emergency services have copays, while primary care visits are covered with no copay. Preventive services like annual physical exams and screenings are covered with no copay, while hearing exams are covered with no copay, and prescription hearing aids are covered up to $1,250 per year. Vision services include routine eye exams and contact lenses with varying copays, and dental services are covered with a $55 copay, and the plan also covers home health services with no copay.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered. For days 1-5, there is a $450 copay, and days 6-90 have no copay.
Outpatient Services See details
Outpatient Services, including outpatient hospital services and observation services, have a $375 copay. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay. Outpatient Substance Abuse Services, including individual and group sessions, have a copay between $30.00 and $30.00.
Partial Hospitalization See details
Partial Hospitalization is covered by the Vermont Blue Advantage Tribute PPO (PPO) plan, and requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Vermont Blue Advantage Tribute PPO (PPO) plan. The plan has a $300 copay for both ground and air ambulance services, with no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered by the Vermont Blue Advantage Tribute PPO (PPO) plan, with a $125 copay and no coinsurance. Urgently needed services have a $40 copay and no coinsurance. Worldwide emergency services are also covered, with a $125 copay for Worldwide Emergency Coverage and Worldwide Emergency Transportation, and a $40 copay for Worldwide Urgent Coverage; this benefit has a maximum plan benefit coverage of $50,000.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay. Chiropractic Services have a $20 copay, and Routine Chiropractic Care has a $30 copay, while Other Chiropractic Services have no copay. Occupational Therapy Services have a $45 copay, and Physician Specialist Services have a $55 copay. Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a $30 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $55 copay, and Additional Telehealth Benefits have a copay ranging from $0 to $55. Other Health Care Professional services have a copay ranging from $0 to $55.
Preventive Services See details
The Vermont Blue Advantage Tribute PPO (PPO) plan covers preventive services with no copay for annual physical exams, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. Additional preventive services include Fitness Benefit, Remote Access Technologies, and Personal Emergency Response System, which may have a copay. The plan does not cover health education, in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services.
Hearing Services See details
Hearing exams are covered with no copay, and routine hearing exams and fitting/evaluation for hearing aids are covered once per year. Prescription hearing aids are covered up to $1,250 per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
The Vermont Blue Advantage Tribute PPO (PPO) plan covers vision services, including routine eye exams with a copay of $0-$55, and eyewear such as contact lenses, eyeglass lenses, eyeglass frames, and upgrades. Contact lenses are covered for one pair per year with a maximum plan benefit coverage amount of $300. Eyeglasses (lenses and frames) are not covered.
Dental Services See details
The Vermont Blue Advantage Tribute PPO (PPO) plan covers Medicare Dental Services with a $55 copay. Other Dental Services include oral exams (3 visits per year), dental x-rays (1 per year), prophylaxis (cleaning) (3 per year), fluoride treatment (1 per year), restorative services (1 visit per year), endodontics (1 visit per lifetime), periodontics (1 visit per year), prosthodontics, removable (1 visit per year), prosthodontics, fixed (1 visit per year), and oral and maxillofacial surgery (unlimited), with various benefit frequency limitations. Orthodontic services are covered up to a $500 maximum per year, while Adjunctive General Services, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Vermont Blue Advantage Tribute PPO (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Vermont Blue Advantage Tribute PPO (PPO) plan, including Durable Medical Equipment (DME) with 0-20% coinsurance, Prosthetics/Medical Supplies with coinsurance for Medicare-covered items, and Diabetic Equipment. Diabetic Supplies have no coinsurance, while Diabetic Therapeutic Shoes/Inserts have 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests, lab services, and outpatient X-ray services, are covered. Diagnostic Procedures/Tests have a copay between $0.00 and $55.00, Lab Services have a $20 copay, and Outpatient X-Ray Services have a $10 copay. Diagnostic Radiological Services have a copay of at most $300.00, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Vermont Blue Advantage Tribute PPO (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 Vermont Blue Advantage Tribute PPO (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Vermont Blue Advantage Tribute PPO (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items with a maximum benefit of $75 every three months, while acupuncture, meal benefits, 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.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved