Blue Cross Medicare Advantage Flex (PPO)
Blue Cross Medicare Advantage Flex (PPO) H4801-014 Plan Details
Blue Cross Medicare Advantage Flex (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H4801-014
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$238.00
Monthly Premium
Blue Cross Medicare Advantage Flex (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H4801-014
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Texas Counties Served
Kaufman
Hall
Live Oak
Zavala
Sutton
Pecos
Gaines
Garza
Mclennan
Freestone
Shackelford
Parker
Hockley
Sherman
Jack
Walker
Orange
Grimes
Kenedy
Limestone
Goliad
Jeff Davis
La Salle
Hopkins
Lynn
Foard
Calhoun
Armstrong
Polk
Camp
Rusk
Gregg
Nueces
Panola
Brooks
Galveston
Cochran
Midland
Hidalgo
Ellis
Waller
Coleman
Andrews
Bell
Young
Henderson
Kleberg
Falls
Tarrant
Frio
Mitchell
Anderson
Houston
Dickens
Coryell
Marion
Ector
Upshur
Titus
Swisher
Hunt
Burleson
Coke
Potter
Mason
Kimble
Randall
Liberty
Collin
Cameron
Upton
Zapata
Castro
Terry
Van Zandt
Irion
Hansford
Carson
Willacy
Donley
Somervell
Crosby
Madison
Leon
Knox
Winkler
Montgomery
Tyler
Presidio
Hamilton
Jim Wells
Bailey
Reeves
Wood
Loving
Oldham
Throckmorton
Brewster
Dimmit
Martin
Howard
Mills
Refugio
Schleicher
Victoria
Hardeman
Bexar
Mcculloch
Stephens
Motley
Robertson
Yoakum
Reagan
Rains
Fisher
Wise
Sterling
Brazoria
Starr
Blanco
Dallas
Hudspeth
Denton
Baylor
Lavaca
Clay
Washington
Kinney
Dallam
Jim Hogg
Haskell
Jackson
Crane
Travis
Borden
Morris
San Patricio
Uvalde
Concho
Grayson
San Augustine
Floyd
Delta
Harrison
Palo Pinto
Webb
Harris
Maverick
Aransas
Deaf Smith
Erath
Hale
Cass
Red River
Wheeler
Karnes
Archer
Shelby
Hutchinson
Williamson
Briscoe
Stonewall
Austin
Dawson
Jefferson
Brazos
Duval
King
Glasscock
Bosque
Lamb
Nacogdoches
Hartley
Menard
De Witt
San Saba
Montague
Culberson
Cherokee
Edwards
Fort Bend
Bee
Tom Green
Trinity
El Paso
Moore
Kent
Runnels
Bowie
Gillespie
Smith
Lubbock
Roberts
Lamar
Franklin
San Jacinto
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $545 |
| Out of Pocket Max |
In-Network: $-1 Out-of-Network: 0 |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 0% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 0% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Copayment for Acute Hospital Services per Stay $0.00 |
| Urgent Care | Copayment for Urgent Care $0.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00 |
| Emergency Room Visit | Copayment for Emergency Care $0.00 Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 0% Coinsurance for Medicare Covered Ambulance Services - Air 0% |
Health Care Services and Medical Supplies
Blue Cross Medicare Advantage Flex (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $0.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 0% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 0% |
| Durable Medical Eqipment (DME) | In-Network: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 0% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 0% Coinsurance for Medicare Covered Lab Services 0% Coinsurance for Medicare Covered Diagnostic Radiological Services 0% Coinsurance for Medicare Covered Therapeutic Radiological Services 0% Coinsurance for Medicare Covered Outpatient X-Ray Services 0% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 0% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $0.00 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 0% Coinsurance for Medicare Covered Group Sessions 0% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 0% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 0% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: Copayment for Skilled Nursing Facility Services per Stay $0.00 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Copayment for Skilled Nursing Facility Services per Stay $0.00 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 0% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 0% Coinsurance for Medicare Covered Eyewear 0% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 0% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 0% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 0% Copayment for Non-Medicare Covered Hearing Aids $699.00 to $999.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% |
Prescription Drug Costs and Coverage
The Blue Cross Medicare Advantage Flex (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $545 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
