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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 Dallas/Austin Houston 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 $142.00. 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:
Sign up for Blue Cross Medicare Advantage Optimum (PPO)
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Drug Coverage
The Blue Cross Medicare Advantage Optimum (PPO) plan features a $300 annual drug deductible. For Tier 1 preferred generic drugs, you will pay no copay when using a preferred pharmacy or preferred mail-order service, while standard options start at a $5 copay for a one-month supply. Tier 2 generic drugs are also highly affordable, costing as little as a $1 copay at preferred locations compared to a $6 standard copay. For brand-name and specialty medications, your costs are determined by coinsurance. Tier 3 preferred brands require a 19% coinsurance at preferred pharmacies and 23% at standard pharmacies, while Tier 4 non-preferred drugs carry a 39% or 41% coinsurance. Tier 5 specialty drugs require a 29% coinsurance for a one-month supply across all pharmacy and mail-order options.
Additional Benefits
The Blue Cross Medicare Advantage Optimum (PPO) plan offers affordable access to everyday care with no copay and no coinsurance for primary care visits, telehealth, home health, and routine preventive services. For hospital care, inpatient stays require a $300 daily copay for days one through six and no copay for subsequent days, while emergency room visits feature a $100 copay. Outpatient hospital services and ambulatory surgery center visits are covered with copays of $350 and $325, respectively, and no coinsurance. Specialist visits and mental health services carry copays ranging from $30 to $50 with no coinsurance, and routine dental, vision, and hearing exams are available with no copay. Durable medical equipment, prosthetics, and dialysis services are covered with a 20% coinsurance and no copay. Additionally, members receive a $25 quarterly allowance for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
Blue Cross Medicare Advantage Optimum (PPO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute care, there is a $300 daily copay for days 1 through 6 and no copay for days 7 and beyond, while psychiatric care requires a $270 daily copay for days 1 through 6 and no copay for days 7 through 90. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric stay days are not covered.
Outpatient Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers outpatient hospital services with a $350 copay and ambulatory surgical center services with a $325 copay, both featuring no coinsurance. Outpatient substance abuse sessions require a $75 copay with no coinsurance, while outpatient blood services are covered with no copay and a 20% 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 for this covered benefit.
Ambulance and Transportation Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers ground ambulance services with a $275 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers emergency services with a $100 copay, which is waived if admitted to the hospital within 3 days, and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered with a $100 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care and telehealth services are covered by Blue Cross Medicare Advantage Optimum (PPO) with no copay and no coinsurance, while specialist visits, therapy, and mental health services require copays ranging from $30 to $50 and no coinsurance. Chiropractic and podiatry services are not covered under this plan.
Preventive Services See details
Preventive services are partially covered by Blue Cross Medicare Advantage Optimum (PPO) with no copay and no coinsurance for covered benefits like annual physical exams, fitness programs, and kidney disease education. However, several sub-services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management, alternative therapies, therapeutic massage, adult day health, home-based palliative care, caregiver support, smoking cessation, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers hearing services, offering routine hearing exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $45 copay and no coinsurance. Prescription hearing aids are partially covered with a $699 to $999 copay and no coinsurance for up to two aids per year, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Blue Cross Medicare Advantage Optimum (PPO) offers partially covered vision services with no coinsurance and no copay for routine eye exams (up to $40 annually) and covered eyewear like contacts, lenses, and frames, which are subject to a combined $100 annual limit. Other eye exams, combined eyeglasses (lenses and frames), and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Blue Cross Medicare Advantage Optimum (PPO), offering Medicare-covered dental for a $45 copay and no coinsurance, and routine exams, cleanings, and x-rays with no copay and no coinsurance. Comprehensive dental benefits have a $750 annual limit with no copay and 0% to 20% coinsurance, but fluoride, implants, orthodontics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Blue Cross Medicare Advantage Optimum (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin has a $35 copay and coinsurance ranging from no coinsurance to 20%.
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 medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, with no copay and a 20% coinsurance. Diabetic supplies feature no coinsurance to 20% coinsurance, and prior authorization is required for these covered benefits.
Diagnostic and Radiological Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers diagnostic and radiological services with prior authorization, featuring no copay or coinsurance for lab services and outpatient X-rays. Diagnostic procedures require a $0 to $100 copay with no coinsurance, diagnostic radiological services start at a $0 copay, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home health services are covered by Blue Cross Medicare Advantage Optimum (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers some cardiac rehabilitation services with no coinsurance and a prior authorization requirement. However, standard cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($30 copay), pulmonary rehabilitation ($15 copay), and SET for PAD services ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Optimum (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required and additional days beyond the Medicare-covered limit are not covered. Patients pay no copay for days 1 to 20 and days 60 to 100, and a $218 daily copay for days 21 to 59, with no prior three-day hospital stay required.
Other Services See details
Blue Cross Medicare Advantage Optimum (PPO) provides partial coverage for other services, which includes over-the-counter (OTC) items with no copay and no coinsurance up to a $25 maximum benefit every three months. Acupuncture and meal benefits are not covered under this plan.
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