Blue Cross Medicare Advantage Secure (HMO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Blue Cross and Blue Shield of Texas
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $22 copay
Out-of-network: $0 copay
Emergency Room
$135 copay
Ambulance Coverage
In-network: $295 copay
Out-of-network: $295 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$100 copay
Out-of-network: $0-$100 copay
Lab services:
In-network: $0-$50 copay
Out-of-network: $0-$50 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$300 copay
Out-of-network: $0-$300 copay
Outpatient x-rays:
In-network: $0-$100 copay
Out-of-network: $0-$100 copay
Hospital Services
Inpatient hospital coverage:
Tier 1
$350 per day for days 1-8
$0 per day for days 9-90
$0 per stay
Outpatient hospital coverage:
In-network: $0-$325 copay
Out-of-network: $0-$325 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $35 copay
Out-of-network: $35 copay
Urgent Care Coverage
$135 copay
Skilled Nursing Facility (SNF)
Tier 1
$0 per day for days 1-20
$218 per day for days 21-39
$0 per day for days 40-100
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $35 copay
Out-of-network: $35 copay
Outpatient individual therapy with a psychiatrist:
In-network: $35 copay
Out-of-network: $35 copay
Outpatient group therapy visits:
In-network: $35 copay
Out-of-network: $35 copay
Outpatient individual therapy visit:
In-network: $35 copay
Out-of-network: $35 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
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Fitting/evaluation:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
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
$1.00 copay (30-day supply)
$3.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (30-day supply)
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
27% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$5.00 copay (30-day supply)
$15.00 copay (90-day supply)
Tier 2: Generic
$6.00 copay (30-day supply)
$18.00 copay (90-day supply)
Tier 3: Preferred Brand
22% coinsurance (30-day supply)
22% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
41% coinsurance (30-day supply)
41% coinsurance (90-day supply)
Tier 5: Specialty Tier
27% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$5.00 copay (30-day supply)
$10.00 copay (90-day supply)
Tier 2: Generic
$6.00 copay (30-day supply)
$12.00 copay (90-day supply)
Tier 3: Preferred Brand
22% coinsurance (30-day supply)
22% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
41% coinsurance (30-day supply)
41% coinsurance (90-day supply)
Tier 5: Specialty Tier
27% 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
$1.00 copay (30-day supply)
$2.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (30-day supply)
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
27% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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