Blue Cross Medicare Advantage Health Choice (PPO)
Blue Cross Medicare Advantage Health Choice (PPO) H1666-014 Plan Details
Blue Cross Medicare Advantage Health Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H1666-014
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$0.00
Monthly Premium
Blue Cross Medicare Advantage Health Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H1666-014
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $545 |
| Out of Pocket Max |
In-Network: $4900 Out-of-Network: 8950 |
| 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 $45.00 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 $250.00 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 $250.00 Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
Blue Cross Medicare Advantage Health Choice (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 Copayment for Medicare-covered Therapeutic Radiological Services $60.00 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 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 |
| 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 Copayment for Non-routine Services $0.00 Copayment for Restorative Services $0.00 Coinsurance for Endodontics 20% Coinsurance for Periodontics 20% Coinsurance for Extractions 20% Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 20% Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 50% 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 |
Prescription Drug Costs and Coverage
The Blue Cross Medicare Advantage Health Choice (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 |
|
| Generic |
|
| Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
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