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2023 Blue Cross Medicare Advantage Classic (PPO)

Blue Cross Medicare Advantage Classic (PPO) H4801-011 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 $6,700 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $6,700 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.



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

Name:Blue Cross Medicare Advantage Classic (PPO)
Plan ID:H4801 011 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:$6,700/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: H4801-012




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 $6,700. Once you spend $6,700 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


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


Eyeglass lenses


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


Eyeglasses (frames and lenses)


VisionNot covered


Other


VisionNot covered


Routine eye exam


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


Upgrades


VisionNot covered



TransportationNot covered
Out-of-Network Skilled Nursing Facility$250 per day for days 1 and beyond
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


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 dentalNot covered


Oral exam


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



In-Network Preventive care$0 copay
Out-of-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 benefitsYes


Inpatient hospital - psychiatric


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


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


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


Outpatient individual therapy visit


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


Outpatient individual therapy visit with a psychiatrist


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


Chemotherapy


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs50% coinsurance


Other Part B drugs


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs50% coinsurance


Diabetes supplies


In-Network Medical equipment/supplies0-20% coinsurance per item
Out-of-Network Medical equipment/supplies20% coinsurance per item


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


In-Network Medical equipment/supplies20% coinsurance per item
Out-of-Network Medical equipment/supplies20% coinsurance per item


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


In-Network Medical equipment/supplies20% coinsurance per item
Out-of-Network Medical equipment/supplies20% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$11,300 In and Out-of-network
$6,700 In-network
$11,300 Out-of-network
Out-of-Network Inpatient hospital coverage$500 per day for days 1 and beyond
In-Network Inpatient hospital coverage$372 per day for days 1 through 5
$0 per day for days 6 through 90


Fitting/evaluation


In-Network Hearing$0 copay
Out-of-Network Hearing50% coinsurance


Hearing aids


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


Hearing exam


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



Health plan deductible$750 annual deductible
Out-of-Network Ground ambulance$275 copay
In-Network Ground ambulance$275 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


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


Specialist


In-Network Doctor visits$31 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


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


Lab services


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


Endodontics


Comprehensive dentalNot covered


Extractions


In-Network Comprehensive dental50% coinsurance
Out-of-Network Comprehensive dental0-50% coinsurance


Non-routine services


Out-of-Network Comprehensive dental0-50% coinsurance
In-Network Comprehensive dental0-50% coinsurance


Periodontics


Comprehensive dentalNot covered


Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered


Restorative services


In-Network Comprehensive dental0% coinsurance
Out-of-Network Comprehensive dental0-50% 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:Bell County MA Plans

Blanco County MA Plans

Bosque County MA Plans

Burleson County MA Plans

Coryell County MA Plans

Falls County MA Plans

Goliad County MA Plans

Hamilton County MA Plans

Karnes County MA Plans

Leon County MA Plans

Limestone County MA Plans

Madison County MA Plans

Mason County MA Plans

McCulloch County MA Plans

McLennan County MA Plans

Mills County MA Plans

Robertson County MA Plans

San Saba County MA Plans

Washington County MA Plans

Zavala 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 $6,700. Once you spend $6,700 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

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.

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