2022 Blue Cross Medicare Advantage Choice Plus (PPO)

Blue Cross Medicare Advantage Choice Plus (PPO) H1666-004 is a 2022 Medicare Advantage Plan or Part-C by Blue Cross and Blue Shield of Texas available to residents in Texas. This plan includes additional prescription drug (Part-D) coverage. The Blue Cross Medicare Advantage Choice Plus (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

Blue Cross Medicare Advantage Choice Plus (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Blue Cross and Blue Shield of Texas works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Cross Medicare Advantage Choice Plus (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of Texas and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Blue Cross and Blue Shield of Texas except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Blue Cross and Blue Shield of Texas Medicare Advantage Plan Costs

Blue Cross Medicare Advantage Choice Plus (PPO) Part-C Premium

Blue Cross and Blue Shield of Texas charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H1666-004 Part-D Deductible and Premium

Blue Cross Medicare Advantage Choice Plus (PPO) has a monthly drug premium of $0.00 and a $480.00 drug deductible. This Blue Cross and Blue Shield of Texas plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Blue Cross and Blue Shield of Texas above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Blue Cross and Blue Shield of Texas Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Blue Cross and Blue Shield of Texas plan does offer additional coverage through the gap.

H1666-004 Formulary or Drug Coverage

Blue Cross Medicare Advantage Choice Plus (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Blue Cross Medicare Advantage Choice Plus (PPO) H1666-004 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$10
Tier 2	$10	$20
Tier 3	$47	$47
Tier 4	$100	$100
Tier 5	25%	25%

*Initial Coverage Phase and 30 day supply

2021 Blue Cross Medicare Advantage Choice Plus (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$750 annual deductible

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	50% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$300-325 copay
Diagnostic tests and procedures	50% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0-100 copay
Lab services	$5-50 copay
Lab services	50% coinsurance (Out-of-Network)
Outpatient x-rays	50% coinsurance (Out-of-Network)
Outpatient x-rays	$5-100 copay

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Doctor Visits

Primary	50% coinsurance per visit (Out-of-Network)
Primary	$20 copay per visit
Specialist	$50 copay per visit
Specialist	50% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$45 copay
Foot exams and treatment	50% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$300 copay (Out-of-Network)
$300 copay

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Hearing

Fitting/evaluation	Not covered
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	$50 copay
Hearing exam	50% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$372 per day for days 1 through 5 $0 per day for days 6 through 90
50% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	20% coinsurance per item (Out-of-Network)
Diabetes supplies	0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	50% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	50% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$270 per day for days 1 through 6 $0 per day for days 7 through 90
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit	$30 copay
Outpatient group therapy visit with a psychiatrist	$30 copay
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$30 copay
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$30 copay
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)

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MOOP

$11,300 In and Out-of-network $7,550 In-network $11,300 Out-of-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

50% coinsurance per visit (Out-of-Network)
$325 copay per visit

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Preventive Care

$0 copay
50% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	Not covered
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	Not covered

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Rehabilitation Services

Occupational therapy visit	50% coinsurance (Out-of-Network)
Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

50% per stay (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	$0 copay
Routine eye exam	$0 copay (Out-of-Network)
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Blue Cross Medicare Advantage Choice Plus (PPO) H1666

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Blue Cross Medicare Advantage Choice Plus (PPO) Plans Performance

Health Plan Customer Service Rating for Blue Cross Medicare Advantage Choice Plus (PPO)

Blue Cross Medicare Advantage Choice Plus (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Blue Cross Medicare Advantage Choice Plus (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.