A non-government entity
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 2026, 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 NM $Mid PPO. This plan received an overall rating of 3 out of 5 stars in 2026.
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 $59.00. 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 $450.00 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:
Sign up for Blue Cross Medicare Advantage Balance (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Blue Cross Medicare Advantage Balance (PPO) plan features an annual prescription drug deductible of $450. For Tier 1 preferred generic drugs, you will pay no copay when using 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. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require an 18% coinsurance at preferred pharmacies, while Tier 4 non-preferred drugs range from 40% to 43% coinsurance. Tier 5 specialty drugs have a 27% coinsurance for a one-month supply regardless of whether you use a preferred or standard pharmacy.
Additional Benefits
The Blue Cross Medicare Advantage Balance (PPO) plan offers robust coverage with no copay and no coinsurance for essential services like primary care visits, telehealth, annual physicals, and lab tests. For hospital care, members pay a daily copay of $325 for the first seven days of inpatient stays and a $325 copay for outpatient hospital services, both with no coinsurance. Emergency room visits require a $100 copay, which is waived if admitted, while urgent care services carry a $40 copay. Specialist visits and physical therapy require copays ranging from $30 to $50 with no coinsurance. Routine dental cleanings, vision exams, and hearing evaluations are available with no copay, alongside a $45 quarterly allowance for over-the-counter items. Additionally, home health services feature no copay, while durable medical equipment and dialysis services require a 20% coinsurance.
Inpatient Hospital See details
Blue Cross Medicare Advantage Balance (PPO) partially covers inpatient hospital services with no coinsurance, requiring a daily copay of $325 for days 1 to 7 of acute stays and $265 for days 1 to 6 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 are covered by Blue Cross Medicare Advantage Balance (PPO) with no coinsurance, featuring a $325 copay for outpatient hospital and observation services, and a $300 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $75 copay with no coinsurance, while outpatient blood services are provided with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Blue Cross Medicare Advantage Balance (PPO) covers partial hospitalization services with a $40.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Blue Cross Medicare Advantage Balance (PPO) covers ambulance services with prior authorization, requiring a $250 copay and no coinsurance for ground ambulance services, and a 20% coinsurance and no copay for air ambulance services. Transportation services are not covered.
Emergency Services See details
Emergency services are covered under the Blue Cross Medicare Advantage Balance (PPO) with a $100 copay and no coinsurance, which is waived if admitted to the hospital within three days, and urgently needed services are covered with a $40 copay and no coinsurance. Worldwide emergency and urgent services are partially covered with a $100 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Blue Cross Medicare Advantage Balance (PPO) primary care benefits are partially covered, offering primary care doctor visits and telehealth with no copay and no coinsurance, while podiatry and chiropractic services are not covered. Other covered services, including specialists, physical therapy, occupational therapy, and mental health care, require copays ranging from $30 to $50 and no coinsurance.
Preventive Services See details
Blue Cross Medicare Advantage Balance (PPO) offers coverage for preventive services, including annual physical exams, kidney disease education, and fitness benefits, with no copays and no coinsurance. However, the benefit is only partially covered as several services, such as health education, nutritional/dietary benefits, and in-home safety assessments, are not covered.
Hearing Services See details
Blue Cross Medicare Advantage Balance (PPO) covers hearing services, featuring Medicare-covered exams for a $40 copay and routine exams or fitting evaluations with no copay, all with no coinsurance. Prescription hearing aids are partially covered with a $699 to $999 copay and no coinsurance for up to two aids per year, while OTC hearing aids and inner ear, outer ear, or over the ear prescription aids are not covered.
Vision Services See details
Vision services are partially covered by Blue Cross Medicare Advantage Balance (PPO), featuring no copay and no coinsurance for routine eye exams and eyewear up to annual plan limits. Other eye exam services, upgrades, and packaged eyeglasses are not covered.
Dental Services See details
Blue Cross Medicare Advantage Balance (PPO) partially covers dental services, featuring a $40 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for preventive services like exams and cleanings. Up to a $750 annual limit, restorative and periodontics services have no copay and no coinsurance, while oral surgery and adjunctive services require a 50% coinsurance and no copay. Other diagnostic services, fluoride treatment, other preventive services, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Blue Cross Medicare Advantage Balance (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Blue Cross Medicare Advantage Balance (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical Equipment is covered by Blue Cross Medicare Advantage Balance (PPO) with no copays, though prior authorization is required. Durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes carry a 20% coinsurance, while diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Blue Cross Medicare Advantage Balance (PPO) with no coinsurance, although prior authorization is required. There is no copay for lab services and outpatient X-rays, while diagnostic procedures and tests range from a $0 to $100 copay, diagnostic radiological services start at a $0 copay, and therapeutic radiological services require a minimum copay of $45.
Home Health Services See details
Home health services are covered under the Blue Cross Medicare Advantage Balance (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Blue Cross Medicare Advantage Balance (PPO) with no coinsurance and required prior authorization, though only some services are covered. Specifically, cardiac rehabilitation (with a $30 copay), intensive cardiac rehabilitation (with a $30 copay), pulmonary rehabilitation (with a $15 copay), and supervised exercise therapy for peripheral artery disease (with a $25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Balance (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 to 20 and 60 to 100, a $218 daily copay for days 21 to 59, and additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Other Services are partially covered under the Blue Cross Medicare Advantage Balance (PPO), which does not cover acupuncture, meal benefits, or naloxone. Over-the-Counter (OTC) items are covered with no copay and no coinsurance, providing a $45 allowance every three months that carries forward if unused.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 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.
We represent 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.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved