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Blue Cross Medicare Advantage Balance (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Cross Medicare Advantage Balance (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 Balance (PPO) in 2025, please refer to our full plan details page.
Blue Cross Medicare Advantage Balance (PPO) is a PPO plan offered by Health Care Service Corporation available for enrollment in 2025 to people living in New Mexico. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Blue Cross Medicare Advantage Balance (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 Balance (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 Balance (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $62.00. 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 $250.00 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 $10100.00 (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 $10100.00 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 Balance (PPO) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you'll pay a $10 copay at a preferred pharmacy and $20 at a standard pharmacy. For preferred brand drugs, you'll pay 48% coinsurance, regardless of the pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Blue Cross Medicare Advantage Balance (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services with varying copays. You can expect no copay for primary care, preventive services, routine hearing exams, and eye exams. However, there are copays for services like specialist visits, mental health, and some outpatient procedures. This plan provides coverage for ambulance services, emergency services, and home health services with no copay. Dental benefits include coverage for oral exams, dental x-rays, and cleaning with no copay, while vision services cover eye exams and eyewear. The plan also includes additional benefits such as an OTC allowance and coverage for skilled nursing facilities.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization required. For Inpatient Hospital-Acute, you will pay a $300 copay for days 1-7 and no copay for days 8-90; for Inpatient Hospital Psychiatric, you will pay a $265 copay for days 1-6 and no copay for days 7-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for outpatient hospital services with a $300 copay, observation services with a $300 copay, ambulatory surgical center services with a $275 copay, individual and group outpatient substance abuse sessions with a $75 copay, and outpatient blood services with no copay. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Cross Medicare Advantage Balance (PPO) plan, but requires prior authorization. You will have a $40 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Cross Medicare Advantage Balance (PPO) plan. Ground Ambulance Services have a $250 copay, while Air Ambulance Services have a 20% coinsurance, and Transportation Services are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Coverage, are covered. Emergency Services have a $100 copay, while Urgently Needed Services have a $40 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage have a $100 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers primary care physician services with no copay, and chiropractic services with a $15 copay. Occupational therapy services have a $40 copay, while physician specialist services have a $38 copay. Mental health and psychiatric services have a $30 copay for individual and group sessions, and physical therapy and speech-language pathology services have a $40 copay. Additional telehealth benefits have no copay, and Opioid Treatment Program Services have a $45 copay.
Preventive Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers preventive services, including an annual physical exam with no copay. Some additional preventive services are also covered, including fitness benefit, and remote access technologies, with no copay, while services like health education, and others are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered; OTC hearing aids are also not covered.
Vision Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers vision services, including eye exams and eyewear. Eye exams and contact lenses have no copay, and eyeglass lenses and frames also have no copay. Eyeglasses (lenses and frames) and upgrades are not covered. There is a combined maximum plan benefit coverage amount of $100 for eyewear every year.
Dental Services See details
Dental services include coverage for Medicare dental services with a $40 copay, oral exams with no copay, dental x-rays with no copay, and prophylaxis (cleaning) with no copay. This plan does not cover fluoride treatment, and orthodontic services are covered with a $1,000 maximum benefit. Restorative services are covered with no coinsurance, while adjunctive general services have a 50% coinsurance, periodontics and oral and maxillofacial surgery have a 20% coinsurance. Endodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, and Implant Services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B insulin drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B chemotherapy/radiation drugs and other Medicare Part B drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Blue Cross Medicare Advantage Balance (PPO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment benefits are covered by the Blue Cross Medicare Advantage Balance (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, and requires authorization. Prosthetics/Medical Supplies - Non-Medicare benefit has a coinsurance for Medicare-covered devices and supplies, and requires authorization. Diabetic Supplies have between 0% and 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures and tests, and lab services, are covered by the Blue Cross Medicare Advantage Balance (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $300, and Therapeutic Radiological Services have a $45 copay, while Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Blue Cross Medicare Advantage Balance (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required, and the copay information is available in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Cross Medicare Advantage Balance (PPO) plan. There is no copay for days 1-20, a $214 copay for days 21-59, and no copay for days 60-100.
Other Services See details
Other Services offered by the Blue Cross Medicare Advantage Balance (PPO) plan include Over-the-Counter (OTC) Items with a maximum benefit of $75.00 every three months, Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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