2023 Blue Cross Medicare Advantage Protect (PPO)

Blue Cross Medicare Advantage Protect (PPO) H4801-019 is a 2023 Medicare Advantage Plan or Part-C by Blue Cross and Blue Shield of OK, TX available to residents in Texas. This plan does not provide extra prescription drug (Part-D) coverage. Blue Cross and Blue Shield of OK, TX Blue Cross Medicare Advantage Protect (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,000 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $5,000 out-of-pocket. This can be an extremely nice safety net.

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 Protect (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of OK, TX and not Original Medicare. With 2023 Medicare Advantage Plan 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 if you sign up for Medicare Advantage in Texas.




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2023 Blue Cross and Blue Shield of OK, TX Medicare Advantage Plan Overview

Name:Blue Cross Medicare Advantage Protect (PPO)
Plan ID:H4801 019 0
Provider:Blue Cross and Blue Shield of OK, TX
Year:2023
Type:Local PPO *
Combined Premium (C+D):$0/mo
MOOP:$5,000/yr
Similar Plan: H4801-020




What type of plan is Blue Cross Medicare Advantage Protect (PPO)

Blue Cross Medicare Advantage Protect (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.

How much does Blue Cross Medicare Advantage Protect (PPO) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Blue Cross and Blue Shield of OK, TX charges a $0 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.


MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Cross Medicare Advantage Protect (PPO) by Blue Cross and Blue Shield of OK, TX MOOP is $5,000. Once you spend $5,000 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.





2023 Summary of Benefits


The benefit information provided is a summary of what Blue Cross Medicare Advantage Protect (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Blue Cross and Blue Shield of OK, TX helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)Covered



Contact lenses


In-Network Vision$0 copay
Out-of-Network Vision$0 copay



Eyeglass frames


In-Network Vision$0 copay
Out-of-Network Vision$0 copay



Eyeglass lenses


Out-of-Network Vision$0 copay
In-Network Vision$0 copay



Eyeglasses (frames and lenses)


VisionNot covered



Other


VisionNot covered



Routine eye exam


In-Network Vision$0 copay
Out-of-Network Vision$0 copay



Upgrades


VisionNot covered




TransportationNot covered
In-Network Skilled Nursing Facility$0 per day for days 1 through 20
$196 per day for days 21 through 49
$0 per day for days 50 through 100
Out-of-Network Skilled Nursing Facility$250 per day for days 1 and beyond



Occupational therapy visit


In-Network Rehabilitation services$40 copay
Out-of-Network Rehabilitation services$75 copay



Physical therapy and speech and language therapy visit


Out-of-Network Rehabilitation services$75 copay
In-Network Rehabilitation services$40 copay



Cleaning


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay



Dental x-ray(s)


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay



Fluoride treatment


Preventive dentalNot covered



Oral exam


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay




Out-of-Network Preventive care$0 copay
In-Network Preventive care$0 copay
In-Network Outpatient hospital coverage$375 copay per visit
Out-of-Network Outpatient hospital coverage$400 copay per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsYes



Inpatient hospital - psychiatric


Out-of-Network Mental health services$500 per day for days 1 and beyond
In-Network Mental health services$290 per day for days 1 through 6
$0 per day for days 7 through 90



Outpatient group therapy visit


Out-of-Network Mental health services$50 copay
In-Network Mental health services$40 copay



Outpatient group therapy visit with a psychiatrist


Out-of-Network Mental health services$50 copay
In-Network Mental health services$40 copay



Outpatient individual therapy visit


In-Network Mental health services$40 copay
Out-of-Network Mental health services$50 copay



Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services$40 copay
Out-of-Network Mental health services$50 copay



Chemotherapy


Out-of-Network Medicare Part B drugs50% coinsurance
In-Network Medicare Part B drugs20% coinsurance



Other Part B drugs


Out-of-Network Medicare Part B drugs50% coinsurance
In-Network Medicare Part B drugs20% coinsurance



Diabetes supplies


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies0-20% coinsurance per item



Durable medical equipment (e.g., wheelchairs, oxygen)


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item



Prosthetics (e.g., braces, artificial limbs)


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item




Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$8,950 In and Out-of-network
$5,000 In-network
$8,950 Out-of-network
In-Network Inpatient hospital coverage$370 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-Network Inpatient hospital coverage$500 per day for days 1 and beyond



Fitting/evaluation


In-Network Hearing$0 copay
Out-of-Network Hearing50% coinsurance



Hearing aids


Out-of-Network Hearing$0 copay
In-Network Hearing$0 copay



Hearing exam


In-Network Hearing$40 copay
Out-of-Network Hearing$75 copay




Health plan deductible$750 annual deductible
In-Network Ground ambulance$275 copay
Out-of-Network Ground ambulance$275 copay



Foot exams and treatment


Out-of-Network Foot care (podiatry services)$75 copay
In-Network Foot care (podiatry services)$40 copay



Routine foot care


Foot care (podiatry services)Not covered



Emergency


Emergency care/Urgent care$90 copay per visit (always covered)



Urgent care


Emergency care/Urgent care$40 copay per visit (always covered)



Primary


Out-of-Network Doctor visits$30 copay per visit
In-Network Doctor visits$0 copay



Specialist


Out-of-Network Doctor visits$75 copay per visit
In-Network Doctor visits$50 copay per visit



Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging$0-300 copay
Out-of-Network Diagnostic procedures/lab services/imaging$400 copay



Diagnostic tests and procedures


Out-of-Network Diagnostic procedures/lab services/imaging$200 copay
In-Network Diagnostic procedures/lab services/imaging$0-100 copay



Lab services


Out-of-Network Diagnostic procedures/lab services/imaging$200 copay
In-Network Diagnostic procedures/lab services/imaging$0-50 copay



Outpatient x-rays


In-Network Diagnostic procedures/lab services/imaging$5-100 copay
Out-of-Network Diagnostic procedures/lab services/imaging$200 copay



Diagnostic services


Comprehensive dentalNot covered



Endodontics


Comprehensive dentalNot covered



Extractions


In-Network Comprehensive dental50% coinsurance
Out-of-Network Comprehensive dental0-50% coinsurance



Non-routine services


In-Network Comprehensive dental0-50% coinsurance
Out-of-Network Comprehensive dental0-50% coinsurance



Periodontics


Comprehensive dentalNot covered



Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered



Restorative services


In-Network Comprehensive dental0% coinsurance
Out-of-Network Comprehensive dental0-50% coinsurance




In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No





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Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Blue Cross Medicare Advantage Protect (PPO) requires you to live in that plan’s service area. The service area is listed below:



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How much does Blue Cross Medicare Advantage Protect (PPO) cost?

Blue Cross and Blue Shield of OK, TX charges a $0 monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage. The premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Blue Cross Medicare Advantage Protect (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Cross Medicare Advantage Protect (PPO) by Blue Cross and Blue Shield of OK, TX MOOP is $5,000. Once you spend $5,000 you will pay nothing for Part A or Part B covered services.

What type of plan is Blue Cross Medicare Advantage Protect (PPO)?

Blue Cross Medicare Advantage Protect (PPO) is a Local PPO *. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.



Source:CMS. Data as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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HealthCompare Insurance Services, HealthPlanOne, LLC, ClearMatch Medicare and Medicare Solutions does not offer every plan available in your area. Currently HealthCompare Insurance Services represent 18 organizations, which offers 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. HealthCompare Insurance Services, HealthPlanOne, LLC, ClearMatch Medicare and Medicare Solutions represents Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.

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