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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 NM $High 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 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 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 $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 Optimum (PPO) plan features a $300 drug deductible and offers highly competitive rates for generic medications. Tier 1 preferred generic drugs have no copay when filled through preferred pharmacies or preferred mail order, while Tier 2 generic drugs require a low $1 copay for a one-month supply at preferred locations. Standard pharmacies and standard mail-order options are also available with slightly higher copays, such as $5 for Tier 1 and $6 for Tier 2 one-month supplies. For higher-tier medications, cost-sharing transitions to coinsurance during the initial coverage phase. Tier 3 preferred brand drugs require a 19% coinsurance at preferred pharmacies and 23% at standard pharmacies, whereas Tier 4 non-preferred drugs carry a 42% or 46% coinsurance depending on where they are filled. Specialty medications in Tier 5 require a flat 29% coinsurance for a one-month supply across all pharmacy and mail-order networks.
Additional Benefits
The Blue Cross Medicare Advantage Optimum (PPO) plan offers robust coverage with affordable cost-sharing, including no copay for primary care visits, telehealth services, and routine preventive care. Emergency room visits require a $100 copay, while urgent care visits have a $40 copay, both with no coinsurance. Inpatient hospital stays require daily copays for the first several days, after which there is no copay for the remainder of the covered stay. Specialist visits and physical therapy are covered with a $40 copay, and home health services are provided with no copay or coinsurance. Routine dental and hearing exams also feature no copay, while prescription hearing aids require a copay of $699 to $999. Additionally, members benefit from a quarterly $65 over-the-counter allowance with no copay, helping to reduce out-of-pocket healthcare expenses.
Inpatient Hospital See details
Blue Cross Medicare Advantage Optimum (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $295 daily copay for days 1 to 7 of acute stays and a $265 daily copay for days 1 to 6 of psychiatric stays, followed by no copay for remaining covered days. Prior authorization is required, and non-Medicare-covered stays as well as additional psychiatric days are not covered.
Outpatient Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers outpatient services with no coinsurance, including a $300 copay for outpatient hospital services, a $295 copay per stay for observation services, and a $275 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $75 copay with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Blue Cross Medicare Advantage Optimum (PPO) covers partial hospitalization services with a $40.00 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 ambulance services with prior authorization, requiring a $250.00 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Transportation services are not covered under this plan.
Emergency Services See details
Emergency services are partially covered by Blue Cross Medicare Advantage Optimum (PPO), offering emergency care with a $100 copay—waived if admitted to the hospital within three days—and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered with a $100 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Blue Cross Medicare Advantage Optimum (PPO) primary care and telehealth services are covered with no copay and no coinsurance, while specialist, physical therapy, and occupational therapy visits require a $40 copay and no coinsurance. Mental health and psychiatric services have a $30 copay and no coinsurance, but podiatry is not covered, and only some chiropractic services are covered since routine and other chiropractic services are not covered.
Preventive Services See details
Blue Cross Medicare Advantage Optimum (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, fitness benefits, remote access technologies, and select screenings. Sub-services that are not covered include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs for chemotherapy-related hair loss, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, safety devices, and counseling.
Hearing Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers hearing services with a $40 copay and no coinsurance for Medicare-covered exams, while annual routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with a $699 to $999 copay and no coinsurance for up to two devices per year, though OTC, inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by Blue Cross Medicare Advantage Optimum (PPO), offering routine eye exams, contact lenses, eyeglass lenses, and eyeglass frames with no copay and no coinsurance. Other eye exam services, upgrades, and eyeglasses (lenses and frames) are not covered.
Dental Services See details
Blue Cross Medicare Advantage Optimum (PPO) offers partially covered dental services, including Medicare-covered dental for a $40 copay and no coinsurance, and preventive care with no copay and no coinsurance. Comprehensive services are covered with no copay and 0% to 20% coinsurance up to a $750 annual limit, but fluoride, implants, orthodontics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin drugs require 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 to receive these covered services.
Medical Equipment See details
Blue Cross Medicare Advantage Optimum (PPO) covers durable medical equipment, prosthetics, and diabetic equipment with no copays, though prior authorization is required. Members will generally pay a 20% coinsurance for these items, with diabetic supplies ranging from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Outpatient X-rays and lab services feature no copay, while diagnostic procedures and tests carry a copay of $0 to $50, and therapeutic radiological services have a minimum copay of $45.
Home Health Services See details
Home health services are covered under the 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, though prior authorization is required and specific sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Optimum (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 through 20 and days 60 through 100, a $218 daily copay for days 21 through 59, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other Services are partially covered by the Blue Cross Medicare Advantage Optimum (PPO) plan, which offers an over-the-counter (OTC) benefit of $65 every three months with no copay and no coinsurance. Acupuncture and meal benefits are not covered under this plan.
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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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