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Blue Cross Medicare Advantage Dental Premier (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.
$0.00
Monthly Premium
Blue Cross Medicare Advantage Dental Premier (PPO) is a PPO plan offered by Health Care Service Corporation
Plan ID: H4801-016
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 Dental Premier (PPO) - H4801-016 by Health Care Service Corporation as well as other Medicare Advantage plans available in your area.
$0.00
Monthly Premium
Texas Counties Served
AndersonAndrewsAransasArcherArmstrongAustinBaileyBaylorBeeBellBexarBlancoBordenBosqueBowieBrazoriaBrazosBrewsterBriscoeBrooksBurlesonCalhounCameronCampCarsonCassCastroCherokeeChildressClayCochranCokeColemanCollinConchoCoryellCraneCrosbyCulbersonDallamDallasDawsonDe WittDeaf SmithDeltaDentonDickensDimmitDonleyDuvalEctorEdwardsEl PasoEllisErathFallsFisherFloydFoardFort BendFranklinFreestoneFrioGainesGalvestonGarzaGillespieGlasscockGoliadGraysonGreggGrimesHaleHallHamiltonHansfordHardemanHarrisHarrisonHartleyHaskellHendersonHidalgoHockleyHopkinsHoustonHowardHudspethHuntHutchinsonIrionJackJacksonJeff DavisJeffersonJim HoggJim WellsKarnesKaufmanKenedyKentKimbleKingKinneyKlebergKnoxLa SalleLamarLambLavacaLeonLibertyLimestoneLive OakLovingLubbockLynnMadisonMarionMartinMasonMaverickMccullochMclennanMenardMidlandMillsMitchellMontagueMontgomeryMooreMorrisMotleyNacogdochesNuecesOldhamOrangePalo PintoPanolaParkerPecosPolkPotterPresidioRainsRandallReaganRed RiverReevesRefugioRobertsRobertsonRunnelsRuskSan AugustineSan JacintoSan PatricioSan SabaSchleicherShackelfordShelbyShermanSmithSomervellStarrStephensSterlingStonewallSuttonSwisherTarrantTerryThrockmortonTitusTom GreenTravisTrinityTylerUpshurUptonUvaldeVan ZandtVictoriaWalkerWallerWashingtonWebbWheelerWillacyWilliamsonWinklerWiseWoodYoakumYoungZapataZavala
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $590 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: 10100 |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2000 |
| Primary Care Doctor Visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $30 |
| Specialty Doctor Visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $75 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $380 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 $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $100 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100 |
| Ambulance Transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275 Coinsurance for Medicare Covered Ambulance Services - Air $20% |
Health Care Services and Medical Supplies
Blue Cross Medicare Advantage Dental Premier (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 | 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. In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Only chiropractic services related to the subluxation of the spine require authorization. |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable Medical Equipment (DME) | Out-of-Network: Medicare Covered Durable Medical Equipment Services: 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 to $100 Copayment for Medicare-covered Lab Services $0 to $50 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 $0 PCP, $42 SPC, $100 OPH. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $100 |
| Home Health Care | Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: $500 per day for days 1 to 999 |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient Services / Surgery | Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $400 Copayment for Medicare Covered Ambulatory Surgical Center Services $350 |
| Outpatient Substance Abuse Care | 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 Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $100 Copayment for Medicare Covered Group Sessions $100 |
| Over-the-counter (OTC) Items | Out-of-Network: Non-Medicare Covered Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0
|
| Podiatry Services | Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $75 In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility Care | Out-of-Network: Skilled Nursing Facility Services: $250 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: Medicare Covered Preventive Dental: Copayment for Office Visit $35 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $0 Coinsurance for Endodontics 20% Coinsurance for Periodontics 0% to 20% Coinsurance for Prothodontics, removable 20% Coinsurance for Maxillofacial prosthetics 20% Coinsurance for Prothodontics, fixed 20% Coinsurance for Maxillofacial surgery 0% to 20% Copayment for Adjunctive general services $0 Maximum Plan Benefit of $5,000 every year |
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 $0 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 $40 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 | 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 |
Prescription Drug Costs and Coverage
The Blue Cross Medicare Advantage Dental Premier (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $590 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|