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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 San Antonio/El Paso/South Texas 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 $77.00. 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 has a $750.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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)
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Drug Coverage
The Blue Cross Medicare Advantage Balance (PPO) plan features an annual drug deductible of $450. For Tier 1 preferred generic drugs, you will pay no copay when using preferred pharmacies or preferred mail-order services. Tier 2 generic medications are also highly affordable, starting at a $1 copay for a one-month supply at preferred locations. Brand-name and specialty drugs are covered under coinsurance, with Tier 3 preferred brands requiring 17% coinsurance at preferred locations and 19% at standard pharmacies. Tier 4 non-preferred drugs carry a 39% or 41% coinsurance, while Tier 5 specialty drugs require a 27% coinsurance for a one-month supply. Choosing preferred pharmacies and mail-order services offers the lowest out-of-pocket costs across all drug tiers under this plan.
Additional Benefits
The Blue Cross Medicare Advantage Balance (PPO) plan offers comprehensive medical coverage with predictable costs, featuring no copay and no coinsurance for preventive services, annual physicals, and telehealth visits. For routine primary care, you will pay a low $5 copay, while specialist visits require a $45 copay. Inpatient hospital stays are covered with no coinsurance, though they require a daily copay for the first six days before transitioning to no copay for the remainder of your stay. Routine dental, vision, and hearing exams are also highly accessible with no copay and no coinsurance, though annual limits apply to hardware like glasses and hearing aids. Emergency room visits carry a $100 copay, while urgent care visits require a $40 copay with no coinsurance. Specialized services such as home health and cardiac rehabilitation are covered with no copay and no coinsurance, while durable medical equipment and dialysis require a 20% coinsurance.
Inpatient Hospital See details
Blue Cross Medicare Advantage Balance (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring prior authorization. Acute stays require a $330 daily copay for days 1 to 6 (with no copay for days 7 and beyond), while psychiatric stays require a $270 daily copay for days 1 to 6 (with no copay for days 7 to 90). Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Blue Cross Medicare Advantage Balance (PPO) covers outpatient hospital, observation, and ambulatory surgical center services with no coinsurance and copays ranging from $320 to $375. Outpatient substance abuse sessions require a $75 copay and no coinsurance, while outpatient blood services feature no copay and a 20% coinsurance.
Partial Hospitalization See details
Partial hospitalization benefits are covered under the Blue Cross Medicare Advantage Balance (PPO) plan 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 ground ambulance services with a $275 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Blue Cross Medicare Advantage Balance (PPO) partially covers emergency services, with worldwide emergency transportation being not covered. Covered emergency services require a $100 copay (waived if admitted within 3 days) and no coinsurance, while urgent care has a $40 copay and worldwide emergency or urgent care has a $100 copay, both with no coinsurance.
Primary Care See details
Blue Cross Medicare Advantage Balance (PPO) covers primary care visits for a $5 copay and specialist visits for a $45 copay, both with no coinsurance, while telehealth services have no copay and no coinsurance. Physical, occupational, and mental health therapies require copays ranging from $30 to $50 with no coinsurance, while podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
Blue Cross Medicare Advantage Balance (PPO) covers preventive services, including annual physical exams, fitness benefits, and glaucoma screenings, with no copay and no coinsurance. However, additional preventive benefits are only partially covered, excluding health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, safety devices, and counseling.
Hearing Services See details
Blue Cross Medicare Advantage Balance (PPO) covers Medicare-covered hearing exams with a $45 copay and no coinsurance, and offers routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with a $699 to $999 copay and no coinsurance, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Blue Cross Medicare Advantage Balance (PPO) offers partially covered vision services with no deductibles, featuring one routine eye exam per year with no copay and no coinsurance up to a $40 annual limit. Covered eyewear, including contact lenses, eyeglass lenses, and frames, also has no copay and no coinsurance up to a $100 yearly limit, while other eye exams, upgrades, and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Dental services are partially covered by Blue Cross Medicare Advantage Balance (PPO), with Medicare-covered dental services requiring a $45.00 copay and no coinsurance. Routine exams, cleanings, and dental X-rays are covered with no copay and no coinsurance, while fluoride, restorative, endodontics, periodontics, prosthodontics, implants, and oral surgery are not covered.
Home Infusion bundled Services See details
Blue Cross Medicare Advantage Balance (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Associated Medicare Part B drugs, such as chemotherapy and insulin, carry no coinsurance to 20% coinsurance, with insulin specifically requiring a $35 copay.
Dialysis Services See details
Blue Cross Medicare Advantage Balance (PPO) covers dialysis services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Blue Cross Medicare Advantage Balance (PPO) covers durable medical equipment, prosthetics, and diabetic equipment with no copay and a 20% coinsurance, though diabetic supplies range from no coinsurance to 20% coinsurance. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Blue Cross Medicare Advantage Balance (PPO) covers diagnostic services with no coinsurance, featuring a $5 copay for lab services and a copay ranging from no copay to $100 for diagnostic procedures. Radiological services are also covered under this plan, requiring a $5 copay for outpatient X-rays, no copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home health services are covered by Blue Cross Medicare Advantage Balance (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no copay and no coinsurance under the Blue Cross Medicare Advantage Balance (PPO) plan. While some services are covered, cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Balance (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, though prior authorization is required. 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 Medicare-covered limit are not covered.
Other Services See details
Other services are not covered under the Blue Cross Medicare Advantage Balance (PPO) plan, which does not provide coverage for acupuncture, over-the-counter (OTC) items, or meal benefits.
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