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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 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 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 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)
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Drug Coverage
The Blue Cross Medicare Advantage Optimum (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for preferred and standard generic drugs, and coinsurance for preferred brand and non-preferred drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. However, if you qualify for the low-income subsidy, your monthly premium will be reduced.
Additional Benefits
The Blue Cross Medicare Advantage Optimum (PPO) plan offers a range of benefits, including inpatient hospital stays with a $275 copay for the first six days, and no copay for days 7-90. Outpatient services, such as primary care visits, are covered with no copay, along with preventive services like annual physical exams, and vision and dental services with copays or coinsurance. This plan also includes coverage for hearing exams, prescription hearing aids, and home health services with no copay. Emergency services, ambulance services, and mental health services are covered with copays, while services like skilled nursing facilities and dialysis services have copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, there is a $275 copay for days 1-6, and no copay for days 7-90; additional days are covered with no copay. For Inpatient Hospital Psychiatric, there is a $270 copay for days 1-6, and no copay for days 7-90; some services are covered, but additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, and ambulatory surgical center (ASC) services. Outpatient hospital and observation services have a $275 copay, while ASC services have a $200 copay. Outpatient substance abuse services have a $75 copay for both individual and group sessions, and outpatient blood services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Cross Medicare Advantage Optimum (PPO) plan, with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Cross Medicare Advantage Optimum (PPO) plan, including both ground and air ambulance services. Ground ambulance services have a $275 copay, while air ambulance services have a 20% coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Blue Cross Medicare Advantage Optimum (PPO) plan, with copays of $100, $40, and $100 respectively, and no coinsurance. Worldwide Urgent Coverage is also covered with a $100 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $40 copay, physician specialist services with a $25 copay, and mental health specialty services with a $30 copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $40 copay, and additional telehealth benefits with no copay. Opioid Treatment Program Services have a $35 copay. However, routine chiropractic care and podiatry services are not covered.
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 are covered, including services like Medicare-covered glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, all with no copay.
Hearing Services See details
Hearing Services include hearing exams with a $45 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, however, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The Blue Cross Medicare Advantage Optimum (PPO) plan covers vision services, including eye exams with no copay. Eyewear has a $40 copay, with a combined maximum of $100 per year for both in-network and out-of-network services, and contact lenses, eyeglass lenses, and eyeglass frames are covered with no copay. However, eyeglasses (lenses and frames) and upgrades are not covered.
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, Restorative Services with no coinsurance, Adjunctive General Services with no coinsurance, Endodontics with 20% coinsurance, Prosthodontics, removable with 20% coinsurance, Maxillofacial Prosthetics with 20% coinsurance, Prosthodontics, fixed with 20% coinsurance, and Oral and Maxillofacial Surgery with 0% - 20% coinsurance. Fluoride Treatment, Implant Services, and Orthodontics are not covered, and Orthodontic Services have a $1500 annual maximum benefit.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
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, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered by the Blue Cross Medicare Advantage Optimum (PPO) plan. Durable Medical Equipment has a 20% coinsurance with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies and Diabetic Supplies have a 20% coinsurance with no copay, whereas Diabetic Therapeutic Shoes/Inserts have a coinsurance between 20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, diagnostic procedures/tests, lab services, and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $100, and Therapeutic Radiological Services have a coinsurance of at least 20%, while 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 plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. 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
Other Services includes coverage for over-the-counter items with no copay and a maximum benefit of $50 every three months. Acupuncture, meal benefits, 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.
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