Blue Cross Medicare Advantage Flex (PPO)

Blue Cross Medicare Advantage Flex (PPO) H4801-014 Plan Details
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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.

$215.40
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.

Blue Cross Medicare Advantage Flex (PPO) H4801-014 Plan Details
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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.

$215.40
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $480
Out of Pocket Max In-Network: $0
Out-of-Network: 0
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
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 $0.00
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:
Copayment for Medicare Covered Physician Specialist Office Visit $0.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0.00
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

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:
Copayment for Medicare Covered Ambulance Services - Ground $0.00
Copayment for Medicare Covered Ambulance Services - Air $0.00

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:
Copayment for Medicare Covered Chiropractic Services $0.00
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:
Copayment for Medicare Covered Diabetic Supplies and Services $0.00
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:
Copayment for Medicare Covered Durable Medical Equipment $0.00
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:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare Covered Lab Services $0.00
Copayment for Medicare Covered Diagnostic Radiological Services $0.00
Copayment for Medicare Covered Therapeutic Radiological Services $0.00
Copayment for Medicare Covered Outpatient X-Ray Services $0.00
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:
Copayment for Medicare Covered Home Health $0.00
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:
Copayment for Medicare Covered Individual Sessions $0.00
Copayment for Medicare Covered Group Sessions $0.00
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:
Copayment for Medicare Covered Outpatient Hospital Services $0.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00
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:
Copayment for Medicare Covered Individual or Group Sessions $0.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $0.00
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:
Copayment for Medicare Covered Comprehensive Dental $0.00

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

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00
Copayment for Medicare Covered Eyewear $0.00

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 $0.00
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $0.00

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:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

    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 $480 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $480 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $15.00
    • Preferred mail order $0.00
    • Standard mail order $15.00
    Generic
    • Preferred retail $5.00
    • Standard retail $20.00
    • Preferred mail order $5.00
    • Standard mail order $20.00
    Annual Drug Deductible $480 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Generic
    • Preferred retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $480 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $45.00
    • Preferred mail order $0.00
    • Standard mail order $45.00
    Generic
    • Preferred retail $15.00
    • Standard retail $60.00
    • Preferred mail order $15.00
    • Standard mail order $60.00