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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 San Antonio/El Paso/South Texas 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 an annual drug deductible of $300. For Tier 1 preferred generic drugs, there is no copay when using preferred pharmacies or preferred mail order services, compared to a $5 copay for a one-month supply at standard locations. Tier 2 generic drugs cost a low $1 copay for a one-month supply at preferred pharmacies and preferred mail order, or $6 at standard locations. For higher-tier medications, costs are calculated as a percentage of the drug cost rather than flat copays. Tier 3 preferred brand drugs require an 18% coinsurance at preferred locations and 20% at standard locations, while Tier 4 non-preferred drugs carry a coinsurance between 41% and 44%. Tier 5 specialty drugs require a flat 29% coinsurance for a one-month supply at both preferred and standard locations.
Additional Benefits
The Blue Cross Medicare Advantage Optimum (PPO) plan offers comprehensive medical coverage with no copay or coinsurance for primary care, telehealth, and preventive visits. Specialist visits require a $30 copay, while emergency room services carry a $100 copay with no coinsurance. For hospital care, inpatient stays require a $275 daily copay for the first six days and no copay thereafter, while outpatient hospital visits have a $320 copay. Routine dental, vision, and hearing exams are covered with no copay, though there are annual coverage limits and cost-sharing for items like hearing aids and comprehensive dental care. Durable medical equipment and dialysis services generally require a 20% coinsurance with no copay. Additionally, home health services are covered with no copay, and members receive a $40 quarterly allowance for over-the-counter items.
Inpatient Hospital See details
Blue Cross Medicare Advantage Optimum (PPO) covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute stays, you pay a $275 daily copay for days 1 through 6 and no copay for days 7 and beyond, whereas psychiatric stays require a $270 daily copay for days 1 through 6 and no copay for days 7 through 90. Non-Medicare-covered stays, psychiatric additional days, and room upgrades are not covered.
Outpatient Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers outpatient hospital services with a $320 copay, and observation and ambulatory surgical center services with a $275 copay, all with no coinsurance. Outpatient substance abuse services are covered with a $75 copay and no coinsurance, while outpatient blood services have no copay and a 20% coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Blue Cross Medicare Advantage Optimum (PPO) with a $40.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Blue Cross Medicare Advantage Optimum (PPO), with ground ambulance services requiring a $275 copay and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay. Prior authorization is required for all ambulance services, and transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers emergency services 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 care are partially covered with a $100 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Blue Cross Medicare Advantage Optimum (PPO) offers primary care and telehealth services with no copay and no coinsurance, while specialist visits and mental health sessions require a $30 copay and no coinsurance. Physical therapy costs a $50 copay and occupational therapy is a $35 copay, both with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by Blue Cross Medicare Advantage Optimum (PPO) with no copay and no coinsurance, including annual physical exams, fitness benefits, remote access technologies, kidney disease education, glaucoma screenings, diabetes self-management, digital rectal exams, and EKGs. However, additional preventive services are only partially covered, as the plan excludes health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for chemotherapy hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, home and bathroom safety devices, and counseling.
Hearing Services See details
Hearing services covered by the Blue Cross Medicare Advantage Optimum (PPO) include Medicare-covered exams for a $45 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $699 to $999 for up to two aids yearly, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Blue Cross Medicare Advantage Optimum (PPO) with no deductible, no copay, and no coinsurance for routine eye exams, contact lenses, eyeglass lenses, and eyeglass frames. These benefits feature an annual limit of $40 for exams and a combined $100 for eyewear, though other eye exam services, upgrades, and eyeglasses (lenses and frames) are not covered.
Dental Services See details
Dental services are partially covered by Blue Cross Medicare Advantage Optimum (PPO), featuring a $45 copay and no coinsurance for Medicare-covered dental. Preventive exams and cleanings have no copay and no coinsurance, while covered comprehensive services have no copay and 0% to 20% coinsurance up to a $750 annual limit. Fluoride, implants, other diagnostic services, and orthodontics 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. Under this plan, Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from 0% (no coinsurance) to 20%, while Medicare Part B insulin drugs require a $35 copay and 0% (no coinsurance) to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Blue Cross Medicare Advantage Optimum (PPO) 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 copay, though prior authorization is required. These covered benefits generally carry a 20% coinsurance, except for diabetic supplies which range from no coinsurance up to 20% coinsurance from specified manufacturers.
Diagnostic and Radiological Services See details
Blue Cross Medicare Advantage Optimum (PPO) covers diagnostic and radiological services, offering no copay for lab services and a $0 to $100 copay with no coinsurance for diagnostic procedures. Outpatient X-rays feature no copay but require coinsurance, while therapeutic radiological services require both a copay and a minimum 20% coinsurance, with prior authorization required for all services.
Home Health Services See details
Home Health Services are covered under the 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 Cardiac Rehabilitation Services with no copay and no coinsurance, though in practice, some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Optimum (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay required, though prior authorization is necessary. There is no copay for days 1 to 20 and days 60 to 100, a $218 daily copay for days 21 to 59, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
Blue Cross Medicare Advantage Optimum (PPO) partially covers Other Services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a $40 allowance every three months. Acupuncture, meal benefits, and Naloxone are not covered under this benefit.
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