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Blue Cross Medicare Advantage Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Cross Medicare Advantage Essential (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 Essential (PPO) in 2026, please refer to our full plan details page.
Blue Cross Medicare Advantage Essential (PPO) is a PPO plan offered by Health Care Service Corporation available for enrollment in 2025 to people living in IL Non-Metro Carve Out 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 Essential (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 Essential (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 Essential (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 $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:
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Drug Coverage
The Blue Cross Medicare Advantage Essential (PPO) plan features a $450 drug deductible and offers cost-effective options for generic medications. For Tier 1 preferred generics, you pay no copay when using a preferred pharmacy or preferred mail-order service. Tier 2 generic drugs are also highly affordable, requiring just a $1 copay for a one-month supply at preferred pharmacies. Brand-name and specialty medications are covered under a coinsurance system based on your pharmacy choice. Tier 3 preferred brands require a 17% coinsurance at preferred pharmacies and 19% at standard pharmacies, while Tier 4 non-preferred drugs range from 39% to 42% coinsurance. Tier 5 specialty drugs have a 27% coinsurance across all network pharmacies for a one-month supply.
Additional Benefits
The Blue Cross Medicare Advantage Essential (PPO) plan offers affordable coverage for core medical needs, featuring no copay for telehealth, preventive care, and home health services. Primary care doctor visits require a low $5 copay, while specialist visits have a $67 copay, and emergency room care is covered with a $125 copay. For inpatient hospital stays, members pay daily copays for the first six days of care and no copay for subsequent days, all with no coinsurance. Routine dental, vision, and hearing exams are also available with no copay, though prescription hearing aids and comprehensive dental care require some cost-sharing. Diagnostic tests, dialysis, and durable medical equipment generally carry a 20% coinsurance with no copay. This plan does not provide coverage for routine transportation, acupuncture, over-the-counter items, or meal benefits.
Inpatient Hospital See details
Blue Cross Medicare Advantage Essential (PPO) covers inpatient hospital services with no coinsurance, though prior authorization is required. Patients pay a $350 daily copay for days 1 to 6 of acute stays and a $295 daily copay for days 1 to 6 of psychiatric stays, with no copay for subsequent Medicare-covered days; however, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Blue Cross Medicare Advantage Essential (PPO) covers outpatient services with no coinsurance, featuring a $0 to $400 copay for outpatient hospital services and a $350 copay per stay for observation services. Ambulatory surgical center and blood services require no copay, while outpatient substance abuse individual and group sessions carry a $75 copay.
Partial Hospitalization See details
Blue Cross Medicare Advantage Essential (PPO) covers partial hospitalization services with a $55 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance services under the Blue Cross Medicare Advantage Essential (PPO) require prior authorization and feature a $225 copay with no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Transportation services to plan-approved or other health-related locations are not covered under this plan.
Emergency Services See details
Blue Cross Medicare Advantage Essential (PPO) covers emergency services with a $125 copay and no coinsurance, which is waived if admitted to the hospital within three days, and urgently needed services with a $50 copay and no coinsurance. Worldwide emergency and urgent care are partially covered with a $125 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Blue Cross Medicare Advantage Essential (PPO) covers primary care visits for a $5 copay and specialist visits for a $67 copay, both with no coinsurance, while telehealth services are available with no copay and no coinsurance. Other covered benefits like therapy, mental health, and psychiatric services carry copays of $30 to $40 and no coinsurance, though podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not.
Preventive Services See details
Blue Cross Medicare Advantage Essential (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits like annual physical exams, fitness benefits, and glaucoma screenings. However, several services are not covered, including health education, weight management programs, personal emergency response systems, and nutritional benefits.
Hearing Services See details
Blue Cross Medicare Advantage Essential (PPO) covers Medicare-covered hearing exams with a $40 copay and routine exams or fitting evaluations with no copay, all with no coinsurance. Prescription hearing aids are partially covered with a copay of $699 to $999 and no coinsurance for up to two devices per year, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Blue Cross Medicare Advantage Essential (PPO) provides partially covered vision services, featuring one annual routine eye exam with no copay and no coinsurance. Covered eyewear has a $35 copay and no coinsurance up to a $100 yearly limit, though other eye exam services, upgrades, and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Blue Cross Medicare Advantage Essential (PPO) dental services are partially covered, featuring a $35 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive cleanings, exams, and x-rays. Comprehensive services are covered up to a $750 annual limit with no copay and up to 50% coinsurance, but implants, orthodontics, fluoride, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the Blue Cross Medicare Advantage Essential (PPO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin drugs have a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Blue Cross Medicare Advantage Essential (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Blue Cross Medicare Advantage Essential (PPO) covers durable medical equipment, prosthetics, medical supplies, 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 Essential (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Members will pay a $5 copay for lab and outpatient X-ray services, copays ranging from $0 to $100 for diagnostic procedures, and a minimum $45 copay for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by Blue Cross Medicare Advantage Essential (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Blue Cross Medicare Advantage Essential (PPO) with no coinsurance and require prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered by this plan.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Essential (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day hospital stay. Patients pay no copay for days 1–20 and 60–100, a $218 daily copay for days 21–59, and additional days beyond Medicare-covered limits are not covered.
Other Services See details
Other services are not covered under the Blue Cross Medicare Advantage Essential (PPO) plan, which does not provide coverage for acupuncture, over-the-counter (OTC) items, or meal benefits.
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