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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 2025, 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 Metro Area. This plan received an overall rating of 3 out of 5 stars in 2025.
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 $250.00 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 Balance (PPO) plan has a $250 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and where you fill your prescription. For example, preferred generic drugs have a $10 copay at preferred pharmacies. For preferred brand drugs, you'll pay 47% coinsurance at a preferred pharmacy, and 50% at a standard pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Blue Cross Medicare Advantage Balance (PPO) plan offers comprehensive coverage with a range of benefits. You can expect a $330 copay for inpatient hospital stays for days 1-6, and no copay for days 7-90. The plan also covers outpatient services, including a $300 copay for outpatient hospital services, a $5 copay for primary care visits, and no copay for many preventive services, including an annual physical exam. The plan also includes coverage for hearing and vision services, with a $45 copay for hearing exams and no copay for routine eye exams. Dental services include a $45 copay for Medicare dental services, and no copay for oral exams, dental x-rays, and prophylaxis (cleaning). Other benefits include home health services with no copay, and skilled nursing facility (SNF) services with no copay for days 1-20 and 60-100.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $330 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you pay a $270 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a $300 copay, observation services with a $300 copay, Ambulatory Surgical Center (ASC) services with a $250 copay, and outpatient substance abuse services with a $75 copay for individual and group sessions. Outpatient blood services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Cross Medicare Advantage Balance (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 Balance (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 under the Blue Cross Medicare Advantage Balance (PPO) plan include a $100 copay with no coinsurance for emergency services and worldwide emergency coverage, and a $40 copay with no coinsurance for urgently needed services. Worldwide emergency transportation is not covered, but worldwide urgent coverage has a $100 copay with no coinsurance.
Primary Care See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers primary care physician services with a $5 copay. Chiropractic services have a $15 copay, but routine care is not covered. Occupational therapy services have a $40 copay. Physician specialist services have a $35 copay. Mental health specialty services have a $30 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $40 copay. Additional telehealth benefits are covered with no copay, and Opioid Treatment Program Services have a $35 copay.
Preventive Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including Medicare-covered Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, have no copay. However, services such as Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers hearing exams with a $45 copay, routine hearing exams with no copay for one exam per year, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, with a copay between $699 and $999 for all types of prescription hearing aids for 2 hearing aids per year. OTC hearing aids are not covered.
Vision Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers vision services, including routine eye exams with no copay and eyewear with a $40 copay. Contact lenses and eyeglass lenses have no copay, and eyeglass frames have no copay; however, eyeglass frames and lenses are limited to one every year, and there is a $100 combined maximum for eyewear.
Dental Services See details
Dental services include Medicare dental services with a $45 copay, oral exams with no copay, dental x-rays with no copay, prophylaxis (cleaning) with no copay, and other services including restorative services and adjunctive general services with no coinsurance, endodontics, prosthodontics, removable, maxillofacial prosthetics and prosthodontics, fixed with 20% coinsurance, periodontics and oral and maxillofacial surgery with coinsurance between 0% and 20%. Fluoride treatment, implant services and orthodontics are not covered. Orthodontic services have a $1000 annual maximum benefit.
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 by the Blue Cross Medicare Advantage Balance (PPO) plan, but require prior authorization. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and prior authorization, Prosthetics/Medical Supplies - Non-Medicare benefit with coinsurance for Medicare-covered items, and Diabetic Equipment. Diabetic Supplies have between 0% and 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Blue Cross Medicare Advantage Balance (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, and Lab Services have a $5 copay. Diagnostic Radiological Services have a copay up to $300, and Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have a $5 copay.
Home Health Services See details
Home Health Services are covered by the Blue Cross Medicare Advantage Balance (PPO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Cross Medicare Advantage Balance (PPO) plan, but require prior authorization. For days 1-20 and 60-100, there is no copay, while days 21-59 have a $214 copay; there is no coinsurance.
Other Services See details
Other Services are not covered by the Blue Cross Medicare Advantage Balance (PPO) plan, including acupuncture, over-the-counter items, meal benefits, and other listed services. No authorization or referrals are required for these services.
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