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Blue Cross Medicare Advantage Health Choice (PPO)

Health Insurance Company: Blue Cross and Blue Shield of Texas

Medicare Advantage Plan Details

Blue Cross and Blue Shield of Texas
$0 /mo
monthly premium
Blue Cross Medicare Advantage Health Choice (PPO)
Additional Coverage
Overall Star Rating (2024)
  • Rx
  • Dental
  • Vision
  • Hearing
3
out of 5 stars

General Plan Details

Medical Deductible
$750
Out-of-Pocket Maximum
$6900
Rx Drug Coverage
Yes
Rx Deductible
$545

Additional Benefits

Dental Coverage
Yes
Vision Coverage
Yes
Mental Health Coverage
Yes
Chiropractic Coverage
No
Optional Supplemental Benefits
No
Part B Give Back
No

Doctor & Hospital Coverage

Primary Doctor Office Visit
In-network: $0 copay
Out-of-network: $30 copay per visit
Specialist Office Visit
In-network: $45 copay per visit
Out-of-network: $75 copay per visit
Periodic Exam Coverage
In-network: $0 copay
Out-of-network: $0 copay

Emergency Room

$100 copay per visit (always covered)

Ambulance Coverage

In-network: $275 copay
Out-of-network: $275 copay

Lab, X-Ray, Radiology Coverage

Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0-100 copay
Out-of-network: $0-200 copay
Medicare-covered lab services: In-network: $0-50 copay
Out-of-network: $30-200 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0-300 copay
Out-of-network: $0-400 copay
Medicare-covered x-ray services: In-network: $0-100 copay
Out-of-network: $30-200 copay

Outpatient Surgery Coverage

Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $375 copay per visit
Out-of-network: $400 copay per visit

Hospitalization Coverage

Inpatient hospital-acute:
In-network: $370 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-network: $500 per day for days 1 and beyond
Inpatient hospital psychiatric:
In-network: $290 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-network: $500 per day for days 1 and beyond

Rehabilitation Coverage

Occupational therapy services:
In-network: $40 copay
Out-of-network: $75 copay
Physical therapy and speech and language therapy services:
In-network: $40 copay
Out-of-network: $75 copay

Urgent Care Coverage

$40 copay per visit (always covered)

Skilled Nursing Facility (SNF)

In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 59
$0 per day for days 60 through 100
Out-of-network: $250 per day for days 1 and beyond

Mental Health Coverage

Medicare-covered individual sessions: In-network: $40 copay
Out-of-network: $50 copay
Medicare-covered group sessions: In-network: $40 copay
Out-of-network: $50 copay

Dental, Vision, Hearing Benefits

Dental Services

Oral exams: In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning): In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays: In-network: $0 copay
Out-of-network: $0 copay

Vision Benefits

Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: $0 copay
Eyewear:
Contact Lenses: In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses: Not covered

Hearing Benefits

Hearing exams:
Routine hearing exams: In-network: $40 copay
Out-of-network: $75 copay
Hearing aids:
Hearing aids (all types): In-network: $699-999 copay
Out-of-network: $699-999 copay

Rx Drug Coverage - Preferred Retail Cost

Tier 1: Preferred Generic

$0.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 2: Generic

$8.00 copay (30-day supply)
$24.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

25% coinsurance (30-day supply)

Rx Drug Coverage - Standard Retail Cost

Tier 1: Preferred Generic

$15.00 copay (30-day supply)
$45.00 copay (90-day supply)

Tier 2: Generic

$20.00 copay (30-day supply)
$60.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

25% coinsurance (30-day supply)

Rx Drug Coverage - Standard Mail Order Cost

Tier 1: Preferred Generic

$15.00 copay (30-day supply)
$45.00 copay (90-day supply)

Tier 2: Generic

$20.00 copay (30-day supply)
$60.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

25% coinsurance (30-day supply)

Rx Drug Coverage - Preferred Mail Order Cost

Tier 1: Preferred Generic

$0.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 2: Generic

$8.00 copay (30-day supply)
$24.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

25% coinsurance (30-day supply)

Plan Links

Plan Link
Doctor Lookup
Drug Link

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Where This Plan is Available

State:
Texas
Counties:
Anderson, Andrews, Aransas, Archer, Armstrong, Austin, Bailey, Baylor, Bee, Bell, Bexar, Blanco, Borden, Bosque, Bowie, Brazoria, Brazos, Brewster, Briscoe, Brooks, Burleson, Calhoun, Cameron, Camp, Carson, Cass, Castro, Cherokee, Clay, Cochran, Coke, Coleman, Collin, Concho, Coryell, Crane, Crosby, Culberson, Dallam, Dallas, Dawson, Deaf Smith, Delta, Denton, De Witt, Dickens, Dimmit, Donley, Duval, Ector, Edwards, Ellis, El Paso, Erath, Falls, Fisher, Floyd, Foard, Fort Bend, Franklin, Freestone, Frio, Gaines, Galveston, Garza, Gillespie, Glasscock, Goliad, Grayson, Gregg, Grimes, Hale, Hall, Hamilton, Hansford, Hardeman, Harris, Harrison, Hartley, Haskell, Henderson, Hidalgo, Hockley, Hopkins, Houston, Howard, Hudspeth, Hunt, Hutchinson, Irion, Jack, Jackson, Jeff Davis, Jefferson, Jim Hogg, Jim Wells, Karnes, Kaufman, Kenedy, Kent, Kimble, King, Kinney, Kleberg, Knox, Lamar, Lamb, La Salle, Lavaca, Leon, Liberty, Limestone, Live Oak, Loving, Lubbock, Lynn, Madison, Marion, Martin, Mason, Maverick, Mcculloch, Mclennan, Menard, Midland, Mills, Mitchell, Montague, Montgomery, Moore, Morris, Motley, Nacogdoches, Nueces, Oldham, Orange, Palo Pinto, Panola, Parker, Pecos, Polk, Potter, Presidio, Rains, Randall, Reagan, Red River, Reeves, Refugio, Roberts, Robertson, Runnels, Rusk, San Augustine, San Jacinto, San Patricio, San Saba, Schleicher, Shackelford, Shelby, Sherman, Smith, Somervell, Starr, Stephens, Sterling, Stonewall, Sutton, Swisher, Tarrant, Terry, Throckmorton, Titus, Tom Green, Travis, Trinity, Tyler, Upshur, Upton, Uvalde, Van Zandt, Victoria, Walker, Waller, Washington, Webb, Wheeler, Willacy, Williamson, Winkler, Wise, Wood, Yoakum, Young, Zapata, Zavala
View all plans in your Texas County

Additional Plan Info

Year:
2024
Plan ID:
H4801-018-0
Insurance Company Website:
Blue Cross and Blue Shield of Texas

Health Insurance Companies Offering Plans

Medicare Advantage and Part D plans and benefits offered by the following carriers:

  • Aetna Medicare
  • Anthem Blue Cross Blue Shield
  • Aspire Health Plan
  • Dean Health Plan
  • Devoted Health
  • GlobalHealth
  • Health Care Service Corporation
  • Cigna Healthcare
  • Humana
  • Medica Central Health Plan
  • Molina Healthcare
  • Mutual of Omaha
  • Premera Blue Cross
  • SCAN Health Plan
  • Scott and White Health Plan now part of Baylor Scott & White Health
  • UnitedHealthcareⓇ
  • Wellcare