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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 2025, 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 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 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 $90.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
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 Optimum (PPO)
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Drug Coverage
The Blue Cross Medicare Advantage Optimum (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have a $10 copay at a preferred pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you will pay nothing for covered drugs. If you qualify for the low-income subsidy (LIS), you will pay $8.20.
Additional Benefits
The Blue Cross Medicare Advantage Optimum (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services like primary care and vision exams are covered with no copay. The plan also includes coverage for dental, hearing, and home health services, and some services require a copay or coinsurance, such as ambulance services, emergency services, and medical equipment. This plan provides additional coverage for things like hearing aids and eyewear, with some limitations. Diagnostic and radiological services have varying copays, and prescription hearing aids are covered with a copay. Overall, the plan aims to provide comprehensive coverage with a combination of copays, coinsurance, and no-cost services depending on the specific benefit.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $250 copay for days 1-7, and no copay for days 8-90. For Inpatient Hospital Psychiatric, you pay a $265 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional days and Non-Medicare-covered stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a $275 copay, observation services with a $275 copay, and ambulatory surgical center services with a $250 copay. Outpatient substance abuse services have a copay of $75 for both individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Cross Medicare Advantage Optimum (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 Optimum (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $250 copay, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgent and Worldwide Emergency services, are covered by the Blue Cross Medicare Advantage Optimum (PPO) plan. Emergency Services have a $100 copay and no coinsurance, while Urgently Needed Services have a $40 copay and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $100 copay and no coinsurance, but Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $40 copay, physician specialist services with a $25 copay, and mental health specialty services with a $30 copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with no copay, and opioid treatment program services with a $45 copay. Routine chiropractic care is not covered.
Preventive Services See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services like Fitness Benefit, and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) may have a copay. Other services like Health Education, and Home and Bathroom Safety Devices and Modifications are not covered.
Hearing Services See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers 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, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include eye exams and eyewear benefits. Eye exams have no copay. Eyewear benefits include contact lenses (no copay), eyeglass lenses (no copay, one pair per year), and eyeglass frames (no copay, one frame per year), and are subject to a combined maximum of $100 per year.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $40 copay, Oral Exams with no copay, Dental X-Rays with no copay, Prophylaxis (Cleaning) with no copay, and Orthodontic Services with a $1,000 annual maximum. Restorative Services and Adjunctive General Services have no coinsurance, while Endodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, and Oral and Maxillofacial Surgery have a 20% coinsurance, and Periodontics has a 0-20% coinsurance. Fluoride Treatment, Implant Services, and Orthodontics 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, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Blue Cross Medicare Advantage Optimum (PPO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered by the Blue Cross Medicare Advantage Optimum (PPO) plan. Durable medical equipment has a 20% coinsurance, and durable medical equipment for use outside the home is not covered. Prosthetic devices and medical supplies have a 20% coinsurance. Diabetic supplies have a coinsurance between 0% and 20%, while diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay between $0 and $50, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $300, Therapeutic Radiological Services have a $45 copay, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Blue Cross Medicare Advantage Optimum (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but there is no information on the cost of services. Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Cross Medicare Advantage Optimum (PPO) plan, but require prior authorization. For days 1-20 and 60-100, there is no copay, and for days 21-59, the copay is $214.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items with no copay, up to $75 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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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.
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