2023 Blue Cross Medicare Advantage Classic (PPO)

Blue Cross Medicare Advantage Classic (PPO) H4801-004 is a 2023 Medicare Advantage Plan or Part-C by Blue Cross and Blue Shield of OK, TX available to residents in Texas. This plan includes extra prescription drug (Part-D) coverage. Blue Cross and Blue Shield of OK, TX Blue Cross Medicare Advantage Classic (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,400 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $6,400 out-of-pocket. This can be an extremely nice safety net.

Blue Cross and Blue Shield of OK, TX 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 Classic (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of OK, TX and not Original Medicare. With 2023 Medicare Advantage Plan 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 OK, TX except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Texas.

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Benefits
Monthly Costs
Formulary and Drugs
Gap coverage
MOOP
Coverage Area

2023 Blue Cross and Blue Shield of OK, TX Medicare Advantage Plan Overview

Name:	Blue Cross Medicare Advantage Classic (PPO)
Plan ID:	H4801 004 0
Provider:	Blue Cross and Blue Shield of OK, TX
Year:	2023
Type:	Local PPO
Combined Premium (C+D):	$0/mo
Part C Premium:	$0/mo
MOOP:	$6,400/yr
Part D (Drug) Premium:	$0/mo
Part D Supplemental Premium	$0/mo
Total Part D Premium:	$0/mo
Drug Deductible:	$200.00/yr
Tiers with No Deductible:	1
Gap Coverage:	No
Benchmark:	Not below the regional benchmark
Type of Medicare Health:	Enhanced Alternative
Drug Benefit Type:	Enhanced
Similar Plan:	H4801-005

What type of plan is Blue Cross Medicare Advantage Classic (PPO)

Blue Cross Medicare Advantage Classic (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.

How much does Blue Cross Medicare Advantage Classic (PPO) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Blue Cross and Blue Shield of OK, TX charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Blue Cross Medicare Advantage Classic (PPO) has a monthly drug premium of $0 and a $200.00 drug deductible. This Blue Cross and Blue Shield of OK, TX plan offers a $0 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. This Premium covers any enhanced plan benefits offered by Blue Cross and Blue Shield of OK, TX above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of 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 OK, TX Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 extra coverage. This Blue Cross and Blue Shield of OK, TX plan does not offer extra coverage through the gap.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Cross Medicare Advantage Classic (PPO) by Blue Cross and Blue Shield of OK, TX MOOP is $6,400. Once you spend $6,400 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and Drug Coverage

Blue Cross Medicare Advantage Classic (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.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$15
Tier 2	$5	$20
Tier 3	$44	$47
Tier 4	$85	$100
Tier 5	29%	29%

The complete Blue Cross Medicare Advantage Classic (PPO) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Blue Cross Medicare Advantage Classic (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Blue Cross and Blue Shield of OK, TX helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

Contact lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

Eyeglass frames

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

Eyeglass lenses

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

Eyeglasses (frames and lenses)

Vision	Not covered

Other

Vision	Not covered

Routine eye exam

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

Upgrades

Vision	Not covered

Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 59 $0 per day for days 60 through 100
Out-of-Network Skilled Nursing Facility	$250 per day for days 1 and beyond

Occupational therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	$75 copay

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	$75 copay

Cleaning

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

Dental x-ray(s)

Out-of-Network Preventive dental	$0 copay
In-Network Preventive dental	$0 copay

Fluoride treatment

Preventive dental	Not covered

Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

Out-of-Network Preventive care	$0 copay
In-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$350 copay per visit
Out-of-Network Outpatient hospital coverage	$400 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	Yes

Inpatient hospital - psychiatric

Out-of-Network Mental health services	$500 per day for days 1 and beyond
In-Network Mental health services	$270 per day for days 1 through 6 $0 per day for days 7 through 90

Outpatient group therapy visit

In-Network Mental health services	$30 copay
Out-of-Network Mental health services	$50 copay

Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	$50 copay
In-Network Mental health services	$30 copay

Outpatient individual therapy visit

In-Network Mental health services	$30 copay
Out-of-Network Mental health services	$50 copay

Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$30 copay
Out-of-Network Mental health services	$50 copay

Chemotherapy

Out-of-Network Medicare Part B drugs	50% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

Other Part B drugs

Out-of-Network Medicare Part B drugs	50% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

Diabetes supplies

In-Network Medical equipment/supplies	0-20% coinsurance per item
Out-of-Network Medical equipment/supplies	20% coinsurance per item

Durable medical equipment (e.g., wheelchairs, oxygen)

Out-of-Network Medical equipment/supplies	20% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	20% coinsurance per item

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$11,300 In and Out-of-network $6,400 In-network $11,300 Out-of-network
In-Network Inpatient hospital coverage	$325 per day for days 1 through 5 $0 per day for days 6 through 90
Out-of-Network Inpatient hospital coverage	$500 per day for days 1 and beyond

Fitting/evaluation

Out-of-Network Hearing	50% coinsurance
In-Network Hearing	$0 copay

Hearing aids

Out-of-Network Hearing	$0 copay
In-Network Hearing	$0 copay

Hearing exam

In-Network Hearing	$50 copay
Out-of-Network Hearing	$75 copay

Health plan deductible	$750 annual deductible
In-Network Ground ambulance	$250 copay
Out-of-Network Ground ambulance	$250 copay

Foot exams and treatment

In-Network Foot care (podiatry services)	$45 copay
Out-of-Network Foot care (podiatry services)	$75 copay

Routine foot care

Foot care (podiatry services)	Not covered

Emergency

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

Urgent care

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

Primary

Out-of-Network Doctor visits	$30 copay per visit
In-Network Doctor visits	$0 copay

Specialist

In-Network Doctor visits	$35 copay per visit
Out-of-Network Doctor visits	$75 copay per visit

Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-300 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$400 copay

Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	$200 copay
In-Network Diagnostic procedures/lab services/imaging	$0-100 copay

Lab services

Out-of-Network Diagnostic procedures/lab services/imaging	$200 copay
In-Network Diagnostic procedures/lab services/imaging	$0-50 copay

Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$5-100 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$200 copay

Diagnostic services

Comprehensive dental	Not covered

Endodontics

Comprehensive dental	Not covered

Extractions

Out-of-Network Comprehensive dental	0-50% coinsurance
In-Network Comprehensive dental	50% coinsurance

Non-routine services

In-Network Comprehensive dental	0-50% coinsurance
Out-of-Network Comprehensive dental	0-50% coinsurance

Periodontics

Comprehensive dental	Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

Restorative services

Out-of-Network Comprehensive dental	0-50% coinsurance
In-Network Comprehensive dental	0% coinsurance

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Blue Cross Medicare Advantage Classic (PPO) requires you to live in that plan’s service area. The service area is listed below:

State:	Texas Medicare
County:	Aransas County MA Plans Bexar County MA Plans Calhoun County MA Plans DeWitt County MA Plans Jackson County MA Plans Lavaca County MA Plans Uvalde County MA Plans Victoria County MA Plans

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How much does Blue Cross Medicare Advantage Classic (PPO) cost?

Blue Cross and Blue Shield of OK, TX charges a $0 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Blue Cross Medicare Advantage Classic (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Cross Medicare Advantage Classic (PPO) by Blue Cross and Blue Shield of OK, TX MOOP is $6,400. Once you spend $6,400 you will pay nothing for Part A or Part B covered services.

What type of plan is Blue Cross Medicare Advantage Classic (PPO)?

Blue Cross Medicare Advantage Classic (PPO) is a Local PPO. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.

Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.