A non-government entity
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 Dallas, Houston, and Austin markets. 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 $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 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 $5800.00 (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 $5800.00 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)
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 Optimum (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will 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 pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Blue Cross Medicare Advantage Optimum (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, and outpatient services have copays and coinsurance depending on the service. Primary care, preventive, and vision services offer some benefits with no copay, while dental services include copays and coinsurance. The plan also covers emergency services, ambulance services, and home health services with copays or coinsurance. Additional benefits include hearing exams, medical equipment, and diagnostic services with copays or coinsurance, with Skilled Nursing Facility (SNF) services having a copay for some days. This plan also covers home infusion bundled services and dialysis services with coinsurance.
Inpatient Hospital See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers inpatient hospital stays, including acute and psychiatric care. For acute inpatient hospital stays, you'll pay a $195 copay for days 1-6, and no copay for days 7-90; additional days are covered with no copay. Psychiatric inpatient stays have a $270 copay for days 1-6, and no copay for days 7-90. Non-Medicare-covered stays and upgrades for both acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $300 copay, Observation Services with a $195 copay, Ambulatory Surgical Center (ASC) Services with a $200 copay, and Outpatient Substance Abuse Services with a $75 copay per session. Outpatient Blood Services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Cross Medicare Advantage Optimum (PPO) plan, but requires prior authorization. You will pay 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. Ground ambulance services have a $275 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 Urgently Needed Services and Worldwide Emergency Coverage, are covered under the Blue Cross Medicare Advantage Optimum (PPO) plan. Emergency Services have a $100 copay, Urgently Needed Services have a $40 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $100 copay; all three have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care services include no copay for Primary Care Physician Services, a $15 copay for Chiropractic Services (but not for Routine Care), a $40 copay for Occupational Therapy Services, a $25 copay for Physician Specialist Services, and a $30 copay for both Individual and Group Sessions for Mental Health Specialty Services. Podiatry Services are not covered, while Other Health Care Professional services have a copay between $0 and $25. Psychiatric Services also have a $30 copay for both Individual and Group Sessions. Physical Therapy and Speech-Language Pathology Services have a $40 copay, while Additional Telehealth Benefits have no copay. Finally, Opioid Treatment Program Services have a $35 copay.
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 Medicare-covered glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit, are also covered with no copay.
Hearing Services See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers hearing exams with a $45 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, along with OTC hearing aids.
Vision Services See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers vision services, including routine eye exams with no copay. Eyewear has a $40 copay, and includes contact lenses with no copay, eyeglass lenses and eyeglass frames with no copay, with a combined maximum of $100 per year. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $45 copay, and other dental services. Oral exams, dental x-rays, and prophylaxis (cleaning) have no copay. Fluoride Treatment and Orthodontics are not covered, and Endodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics have 20% coinsurance, and Periodontics and Oral and Maxillofacial Surgery have 0% to 20% coinsurance.
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 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 is covered by the Blue Cross Medicare Advantage Optimum (PPO) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Prosthetic Devices have a 20% coinsurance. Medical Supplies have a 20% coinsurance, while Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a copay of up to $100 for Diagnostic Procedures/Tests, no copay for Lab Services, and a copay of up to $300 for Diagnostic Radiological Services. Therapeutic Radiological Services have a coinsurance of at least 20%, 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. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, SET for PAD Services, and Additional Cardiac Rehabilitation Services are not covered. Prior authorization is required for this benefit.
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. There is no copay for days 1-20 and days 60-100, but there is a $214 copay for days 21-59.
Other Services See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers Over-the-Counter (OTC) Items with no copay, up to a maximum of $50 every three months, and offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit. 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.
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