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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 Oklahoma. 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 $82.00. 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 $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 $8950.00 (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 $8950.00 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 is met, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $10 copay at a preferred pharmacy, while preferred brand drugs have a 46% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you'll pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you may have a reduced premium. You should consult the plan's formulary for specific drug coverage details.
Additional Benefits
The Blue Cross Medicare Advantage Balance (PPO) plan offers a wide range of benefits, including inpatient and outpatient hospital services, with varying copays depending on the specific service. Emergency, urgent, and primary care services are covered with copays, and preventive services like annual physical exams have no copay. The plan also covers hearing, vision, and dental services, with copays and coinsurance for specific services like hearing exams and eyewear. This plan provides additional coverage for services like ambulance, home health, and skilled nursing facilities with copays or coinsurance in some cases. Diagnostic and radiological services are covered, with copays for certain procedures. The plan also offers an over-the-counter (OTC) allowance and covers home infusion, dialysis, and medical equipment.
Inpatient Hospital See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers inpatient hospital services, including acute and psychiatric care, with prior authorization required. For Inpatient Hospital-Acute, you will pay a $325 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you will pay a $225 copay for days 1-7, and no copay for days 8-90. Additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $325 copay, ambulatory surgical center services have a $200 copay, and outpatient blood services have no copay. Individual and group sessions for outpatient substance abuse have a copay of $75.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Cross Medicare Advantage Balance (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a $250 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, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Blue Cross Medicare Advantage Balance (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $120 copay, while Urgently Needed Services have a $40 copay, and all three have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Primary Care Physician Services have no copay, Chiropractic Services have a $20 copay, Occupational Therapy Services have a $40 copay, Physician Specialist Services have a $39 copay, and Physical Therapy and Speech-Language Pathology Services have a $40 copay. Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a $30 or $45 copay depending on the specific service. Other Health Care Professional services have a copay between $0 and $39. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers preventive services, including an annual physical exam with no copay. The plan also covers additional preventive services, with no copay for Medicare-covered Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Other services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, and Telemonitoring Services are not covered.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $40 copay, while routine hearing exams have no copay, and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered, but inner ear, outer ear, and over the ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers vision services, including eye exams with no copay. Eyewear has a $35 copay, and this benefit includes contact lenses with no copay, eyeglass lenses and eyeglass frames with no copay, and a combined maximum benefit of $100 per year. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
The Blue Cross Medicare Advantage Balance (PPO) plan covers dental services, including oral exams with no copay, dental X-rays with no copay, and prophylaxis (cleaning) with no copay. Other services include restorative services with no coinsurance, adjunctive general services with 50% coinsurance, periodontics with 20% coinsurance, and oral and maxillofacial surgery with 20% coinsurance. Fluoride treatment, implant services, and orthodontics are not covered, and endodontics, prosthodontics (removable and fixed), and maxillofacial prosthetics are offered as optional, supplemental benefits.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
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 is covered, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with varying coinsurance. Durable Medical Equipment for use outside the home is not covered.
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, while Lab Services have a $5 copay. Diagnostic Radiological Services have a copay of at most $300, Therapeutic Radiological Services have a copay of $45, and Outpatient X-Ray Services have no 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. 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 any of the sub-services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20 and 50-100, there is no copay, while days 21-49 have a $214 copay.
Other Services See details
Other Services for the Blue Cross Medicare Advantage Balance (PPO) plan cover over-the-counter (OTC) items with a maximum benefit coverage amount of $50 every three months, and the plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit. Acupuncture, meal benefits, and many other services are not covered.
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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.
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