Blue Cross Medicare Advantage Flex (PPO)

Blue Cross Medicare Advantage Flex (PPO) H4801-013 Plan Details
3 out of 5 stars

Blue Cross Medicare Advantage Flex (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H4801-013

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.

$202.00
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: H4801-013

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.

Blue Cross Medicare Advantage Flex (PPO) H4801-013 Plan Details
3 out of 5 stars

Blue Cross Medicare Advantage Flex (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H4801-013

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.

$202.00
Monthly Premium

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
  • Maximum 1 Routine Eye Exam every year

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
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    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
    • Standard mail order $15.00
    • Preferred cost-share retail $0.00
    • Standard retail $15.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $20.00
    • Preferred cost-share retail $8.00
    • Standard retail $20.00
    • Preferred cost-share mail order $8.00
    Annual Drug Deductible $545 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $30.00
    • Preferred cost-share retail $0.00
    • Standard retail $30.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $40.00
    • Preferred cost-share retail $16.00
    • Standard retail $40.00
    • Preferred cost-share mail order $16.00
    Annual Drug Deductible $545 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $45.00
    • Preferred cost-share retail $0.00
    • Standard retail $45.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $60.00
    • Preferred cost-share retail $24.00
    • Standard retail $60.00
    • Preferred cost-share mail order $24.00