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Blue Cross Medicare Advantage Classic (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$45.00
Monthly Premium
Blue Cross Medicare Advantage Classic (PPO) is a PPO plan offered by Health Care Service Corporation
Plan ID: H0107-003
HelpAdvisor Editorial Team analysis of data from the 2025 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.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Blue Cross Medicare Advantage Classic (PPO) - H0107-003 by Health Care Service Corporation as well as other Medicare Advantage plans available in your area.
$45.00
Monthly Premium
Montana Counties Served
BeaverheadBig HornBroadwaterCarbonCascadeChouteauCusterDeer LodgeDivideFergusFlatheadGallatinGlacierGolden ValleyGraniteHillIdahoJeffersonJudith BasinLakeLewis And ClarkLibertyLincolnMadisonMckenzieMeagherMineralMissoulaMusselshellParkPonderaPowellRavalliRosebudSandersSilver BowStillwaterSweet GrassTetonTooleWheatlandYellowstone
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5800 Out-of-Network: 9950 |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $7 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $375 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent Care | Urgent Care: Copayment for Urgent Care $30 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $120 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $290 Air Ambulance: Coinsurance for Air Ambulance Services $20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Blue Cross Medicare Advantage Classic (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: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20 Prior Authorization Required for Chiropractic Services Only chiropractic services related to the subluxation of the spine require authorization. Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $75 Only chiropractic services related to the subluxation of the spine require authorization. |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 20% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| 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 to $50 Copayment for Medicare-covered Lab Services $5 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $0 copay for the Diagnostic Bone Mass Measurement and Diagnostic Colonoscopy test performed on the same date of service as the corresponding preventive test. All other services are covered at a $50 copay. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $250 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered X-Ray Services 20% |
| Home Health Care | Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 35% |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: $500 per day for days 1 to 999 |
| Mental Health Outpatient Care | Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $50 Copayment for Medicare Covered Group Sessions $50 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $395 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $375 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $275 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient Substance Abuse Care | Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $100 Copayment for Medicare Covered Group Sessions $100 In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $75 Copayment for Medicare-covered Group Sessions $75 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter (OTC) Items | |
| Podiatry Services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45 Prior Authorization Required for Podiatry Services Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $75 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 49 $0 per day for days 50 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Out-of-Network: Medicare Covered Preventive Dental Services: Copayment for Medicare Covered Preventive Dental $75 |
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 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $45 Copayment for Contact Lenses $0 Copayment for Eyeglass Lenses $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 $45 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $699 to $999
|
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 | Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |