Plan Benefits for
2022 Blue Cross Medicare Advantage Classic (PPO)


Blue Cross Medicare Advantage Classic (PPO) H4801-006 is a 2022 Medicare Advantage Plan or Medicare Part-C plan by Blue Cross and Blue Shield of OK, TX available to residents in Texas. This plan includes additional Medicare prescription drug (Part-D) coverage. The Blue Cross Medicare Advantage Classic (PPO) has a monthly premium of $0 and has an in-network Maximum Out-of-Pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out-of-pocket. This can be a extremely nice safety net.

Blue Cross Medicare Advantage Classic (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Blue Cross and Blue Shield of OK, TX works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Cross Medicare Advantage Classic (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of OK, TX and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Blue Cross and Blue Shield of OK, TX except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.




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2022 Blue Cross and Blue Shield of OK, TX Medicare Advantage Plan Costs

Name:
Blue Cross Medicare Advantage Classic (PPO)
Plan ID:
H4801-006
Provider:Blue Cross and Blue Shield of OK, TX
Year:2022
Type: Local PPO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $5,900
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$350.00
Tiers with No Deductible:1
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H4801-007




Blue Cross Medicare Advantage Classic (PPO) Part-C Premium

Blue Cross and Blue Shield of OK, TX plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



H4801-006 Part-D Deductible and Premium

Blue Cross Medicare Advantage Classic (PPO) has a monthly drug premium of $0.00 and a $350.00 drug deductible. This Blue Cross and Blue Shield of OK, TX plan offers a $0.00 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Blue Cross and Blue Shield of OK, TX above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.



Blue Cross and Blue Shield of OK, TX Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Blue Cross and Blue Shield of OK, TX plan does offer additional coverage through the gap.



H4801-006 Formulary or Drug Coverage

Blue Cross Medicare Advantage Classic (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each Tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Blue Cross Medicare Advantage Classic (PPO) H4801-006 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $10
Tier 2 $10 $20
Tier 3 $47 $47
Tier 4 $100 $100
Tier 5 27% 27%
*Initial Coverage Phase and 30 day supply








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1-855-778-4180
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Sun 9am-6pm EST




Coverage Area for Blue Cross Medicare Advantage Classic (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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