Blue Cross Medicare Advantage Protect (PPO)
Blue Cross Medicare Advantage Protect (PPO) H4801-019 Plan Details
Blue Cross Medicare Advantage Protect (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H4801-019
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.
$0.00
Monthly Premium
Blue Cross Medicare Advantage Protect (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H4801-019
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
Live Oak
Hall
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
Armstrong
Calhoun
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
Winkler
Leon
Knox
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
Harrison
Delta
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
Lamb
Bosque
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 | $-1 |
| Out of Pocket Max |
In-Network: $6350 Out-of-Network: 9550 |
| 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: Copayment for Medicare Covered Primary Care Office Visit $30.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $50.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $75.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $370.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: $500.00 per day for days 1 to 999 |
| Urgent Care | Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120.00 |
| Emergency Room Visit | Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275.00 Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
Blue Cross Medicare Advantage Protect (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 $20.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $75.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% 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 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| 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 to $100.00 Copayment for Medicare-covered Lab Services $0.00 to $50.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $300.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $100.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $200.00 Copayment for Medicare Covered Lab Services $30.00 to $200.00 Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $400.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Copayment for Medicare Covered Outpatient X-Ray Services $30.00 to $200.00 |
| 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 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $290.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: $500.00 per day for days 1 to 999 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual Sessions $50.00 Copayment for Medicare Covered Group Sessions $50.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $375.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $370.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $300.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $400.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $350.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $75.00 Copayment for Medicare-covered Group Sessions $75.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $100.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Podiatry Services $75.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 49 $0.00 per day for days 50 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: $250.00 per day for days 1 to 999 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $35.00 Coinsurance for Non-routine Services 0% to 50% Copayment for Restorative Services $0.00 Coinsurance for Extractions 50% Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $75.00 Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 50% |
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 Copayment for Contact Lenses $0.00 Copayment for Eyeglass Lenses $0.00
Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $75.00 Copayment for Medicare Covered Eyewear $75.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-Medicare Covered Eyewear $0.00 Maximum Plan Benefit of $40.00 |
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 $40.00 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: Copayment for Medicare Covered Hearing Exams $75.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 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: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
