2023 Blue Cross Medicare Advantage Flex (PPO)

Blue Cross Medicare Advantage Flex (PPO) H4801-014 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 Flex (PPO) has a monthly premium of $213.00 and has an in-network maximum out-of-pocket limit of $- (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $- 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 Flex (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
Premium Assistance
Coverage Area

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

Name:	Blue Cross Medicare Advantage Flex (PPO)
Plan ID:	H4801 014 0
Provider:	Blue Cross and Blue Shield of OK, TX
Year:	2023
Type:	Local PPO
Combined Premium (C+D):	$213.00/mo
Part C Premium:	$202.50/mo
MOOP:	$-/yr
Part D (Drug) Premium:	$10.50/mo
Part D Supplemental Premium	$0/mo
Total Part D Premium:	$10.50/mo
Drug Deductible:	$505.00/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:	H4801-015

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

Blue Cross Medicare Advantage Flex (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 Flex (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 $213.00 consolidated premium. The Part C premium is $202.50 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 Flex (PPO) has a monthly drug premium of $10.50 and a $505.00 drug deductible. This Blue Cross and Blue Shield of OK, TX plan offers a $10.50 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 $10.50. 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.

Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Blue Cross Medicare Advantage Flex (PPO) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $2.60 for 75% low-income subsidy $5.20 for 50% and $7.90 for 25%.

Full Assistance Premium:	$0
75% Assistance Premium:	$2.60
50% Assistance Premium:	$5.20
25% Assistance Premium:	$7.90

Formulary and Drug Coverage

Blue Cross Medicare Advantage Flex (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	25%	25%

The complete Blue Cross Medicare Advantage Flex (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 Flex (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

Vision	Not covered

Eyeglass frames

Vision	Not covered

Eyeglass lenses

Vision	Not covered

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 copay
Out-of-Network Skilled Nursing Facility	$0 copay

Occupational therapy visit

In-Network Rehabilitation services	$0 copay
Out-of-Network Rehabilitation services	$0 copay

Physical therapy and speech and language therapy visit

Out-of-Network Rehabilitation services	$0 copay
In-Network Rehabilitation services	$0 copay

Cleaning

Preventive dental	Not covered

Dental x-ray(s)

Preventive dental	Not covered

Fluoride treatment

Preventive dental	Not covered

Oral exam

Preventive dental	Not covered

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

Inpatient hospital - psychiatric

Out-of-Network Mental health services	$0 copay
In-Network Mental health services	$0 copay

Outpatient group therapy visit

Out-of-Network Mental health services	$0 copay
In-Network Mental health services	$0 copay

Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$0 copay

Outpatient individual therapy visit

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$0 copay

Outpatient individual therapy visit with a psychiatrist

Out-of-Network Mental health services	$0 copay
In-Network Mental health services	$0 copay

Chemotherapy

In-Network Medicare Part B drugs	$0 copay
Out-of-Network Medicare Part B drugs	$0 copay

Other Part B drugs

In-Network Medicare Part B drugs	$0 copay
Out-of-Network Medicare Part B drugs	$0 copay

Diabetes supplies

Out-of-Network Medical equipment/supplies	$0 copay
In-Network Medical equipment/supplies	$0 copay

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

Out-of-Network Medical equipment/supplies	$0 copay
In-Network Medical equipment/supplies	$0 copay

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

In-Network Medical equipment/supplies	$0 copay
Out-of-Network Medical equipment/supplies	$0 copay

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$0 In and Out-of-network $0 In-network $0 Out-of-network
In-Network Inpatient hospital coverage	$0 copay
Out-of-Network Inpatient hospital coverage	$0 copay

Fitting/evaluation

Hearing	Not covered

Hearing aids - inner ear

Hearing	Not covered

Hearing aids - outer ear

Hearing	Not covered

Hearing aids - over the ear

Hearing	Not covered

Hearing exam

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

Health plan deductible	$0
Out-of-Network Ground ambulance	$0 copay
In-Network Ground ambulance	$0 copay

Foot exams and treatment

In-Network Foot care (podiatry services)	$0 copay
Out-of-Network Foot care (podiatry services)	$0 copay

Routine foot care

Foot care (podiatry services)	Not covered

Emergency

Emergency care/Urgent care	$0 copay

Urgent care

Emergency care/Urgent care	$0 copay

Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$0 copay

Specialist

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$0 copay

Diagnostic radiology services (e.g., MRI)

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

Diagnostic tests and procedures

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

Lab services

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

Outpatient x-rays

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

Diagnostic services

Comprehensive dental	Not covered

Endodontics

Comprehensive dental	Not covered

Extractions

Comprehensive dental	Not covered

Non-routine services

Comprehensive dental	Not covered

Periodontics

Comprehensive dental	Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

Restorative services

Comprehensive dental	Not covered

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 Flex (PPO) requires you to live in that plan’s service area. The service area is listed below:

State:	Texas Medicare

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

Blue Cross and Blue Shield of OK, TX charges a $213.00 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 Flex (PPO) MOOP?

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

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

Blue Cross Medicare Advantage Flex (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.