Medicare HMO Blue (HMO)
- You must receive services in the Medicare HMO service area, which is all of Massachusetts except Nantucket, Dukes, and Berkshire counties.
- You must choose a Medicare HMO Blue primary care provider to coordinate your care and get specialist referrals when necessary.
- This plan includes prescription drug coverage.
Learn more about this plan
Deductible Cost
A deductible is the amount you pay before your insurance provider begins paying any of the costs for certain services during each calendar year. Your deductible under this plan is:
- Calendar-Year Deductible: $0
Out-of-pocket maximum
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-ofpocket limit has been met. Your out-of-pocket under this plan is:
- Calendar-year: $3,400
Copayments
- Medicare-covered preventive care and screening tests: Nothing
- Doctor’s office visits
- Primary care provider : $15 per visit
- Specialty care: $35 per visit
- Emergency Care: $75 per visit
- Inpatient Hospital Care: $150 per day—days 1-5
- CT scan, MRIs, PET scans, and nuclear cardiac imaging tests: $150 per day
- X-rays: $5 per day
- Lab tests and other diagnostic tests: $10 per day
Pharmacy coverage
This plan includes prescription drug coverage. Covered medications are separated into three tiers, and the amount a member pays depends on the medication’s tier.
| Prescription Drug Benefit | Member Pays (In-Network Costs) |
|---|---|
| Retail pharmacies | $10 generic drugs $25 preferred brand drugs $45 non-preferred brand drugs |
| Mail order supply | $20 generic drugs $50 preferred brand drugs $115 non-preferred brand drugss |
Plan Documents
