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Blue Cross Medicare Advantage Optimum (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Cross Medicare Advantage Optimum (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Cross Medicare Advantage Optimum (PPO) in 2026, please refer to our full plan details page.
Blue Cross Medicare Advantage Optimum (PPO) is a PPO plan offered by Health Care Service Corporation available for enrollment in 2025 to people living in MT High PPO. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Blue Cross Medicare Advantage Optimum (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Cross Medicare Advantage Optimum (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Blue Cross Medicare Advantage Optimum (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $128.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $300.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $8950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $8950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Blue Cross Medicare Advantage Optimum (PPO) plan features a $300 annual drug deductible before coverage begins for certain tiers. For Tier 1 preferred generic drugs, members pay no copay when utilizing a preferred pharmacy or preferred mail order service. Tier 2 generic drugs are also highly affordable, with copays starting at just $1 for a one-month supply at preferred locations. Higher-tier medications are subject to coinsurance, with Tier 3 preferred brands requiring an 18% coinsurance at preferred pharmacies compared to 21% at standard pharmacies. Tier 4 non-preferred drugs carry a 39% to 41% coinsurance, while Tier 5 specialty drugs require a 29% coinsurance across all pharmacy types. Utilizing preferred pharmacies and mail-order options offers the lowest out-of-pocket costs for prescription drugs under this plan.
Additional Benefits
The Blue Cross Medicare Advantage Optimum (PPO) plan offers affordable healthcare coverage with no copay and no coinsurance for primary care visits, telehealth, and home health services. For more intensive care, members pay no coinsurance and fixed copays, including up to $40 for specialist visits, $120 for emergency services, and $350 per day for the first six days of acute inpatient hospital stays. Outpatient hospital services also feature no coinsurance and a $350 copay, while ground ambulance services require a $290 copay. Valuable extra benefits are built into the plan, including routine dental, vision, and hearing exams with no copay. Prescription hearing aids are partially covered with copays ranging from $699 to $999, while comprehensive dental services are covered up to a $750 annual limit with no copay. Durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance, and members receive a $25 quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
Blue Cross Medicare Advantage Optimum (PPO) covers inpatient hospital care with no coinsurance, requiring a daily copay of $350 for days 1 through 6 of acute stays and $324 for days 1 through 5 of psychiatric stays, with no copay for subsequent days. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient Services covered by Blue Cross Medicare Advantage Optimum (PPO) feature no coinsurance across all services, with copays of $350 for outpatient hospital services, $275 per stay for observation services, and $300 for ambulatory surgical center visits. Outpatient substance abuse sessions require a $75 copay, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Blue Cross Medicare Advantage Optimum (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers ground ambulance services with a $290 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. Transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers emergency services with a $120 copay (waived if admitted within 3 days) and urgently needed services with a $25 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered with a $120 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Blue Cross Medicare Advantage Optimum (PPO) covers primary care provider visits and telehealth services with no copay and no coinsurance. Specialist visits, therapies, and mental health services are covered with no coinsurance and copays ranging up to $40, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered by the Blue Cross Medicare Advantage Optimum (PPO) plan with no copay and no coinsurance for covered services such as annual physical exams, fitness benefits, and remote access technologies. However, several services are not covered, including health education, in-home safety assessments, PERS, medical nutrition therapy, weight management, alternative therapies, therapeutic massage, nutritional/dietary benefits, palliative care, in-home support, caregiver support, tobacco cessation, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers Medicare-covered hearing exams with a $45 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay of $699 to $999 for up to two aids per year, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Blue Cross Medicare Advantage Optimum (PPO) vision services are partially covered with no deductible or coinsurance. Routine eye exams are covered once yearly with no copay up to a $40 limit, and eyewear is covered up to a $100 annual limit with no copay for contact lenses, individual lenses, and frames, while other eye exams, upgrades, and combined eyeglasses are not covered.
Dental Services See details
Blue Cross Medicare Advantage Optimum (PPO) partially covers dental services, including Medicare-covered dental for a $45 copay and no coinsurance, and preventive care like exams, cleanings, and X-rays with no copay or coinsurance. Comprehensive services are covered up to a $750 annual limit with no copay and coinsurance ranging from 0% to 50%, but fluoride, implants, orthodontics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers Home Infusion bundled Services with no copay, although prior authorization is required. Under this benefit, covered Part B chemotherapy, radiation, and other drugs require no copay and no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these covered services.
Medical Equipment See details
Blue Cross Medicare Advantage Optimum (PPO) covers medical equipment, prosthetics, and diabetic equipment with no copays and a 20% coinsurance, except for diabetic supplies which range from no coinsurance to 20% coinsurance. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers diagnostic services with no coinsurance and copays ranging from no copay to $50 for tests and a $5 copay for lab services. Radiological services are also covered under the plan, requiring a 20% coinsurance for outpatient X-rays and therapeutic services, while diagnostic radiological services start at no copay.
Home Health Services See details
Home health services are covered by Blue Cross Medicare Advantage Optimum (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers some cardiac rehabilitation services with no coinsurance and prior authorization required, although standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Optimum (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, as additional days beyond the Medicare-covered limit are not covered. Patients pay no copay for days 1 through 20 and days 40 through 100, a $218 daily copay for days 21 through 39, and prior authorization is required.
Other Services See details
Blue Cross Medicare Advantage Optimum (PPO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a $25 quarterly limit that carries forward if unused. Acupuncture, meal benefits, and naloxone are not covered under this benefit.
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