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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 2025, 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 Rockford, Peoria, Springfield, & St. Louis Markets. This plan received an overall rating of 3.5 out of 5 stars in 2025.
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 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 $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 has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, preferred generic drugs have a $10 copay at preferred pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. Note that if you qualify for the low-income subsidy (LIS), your Part D costs are $0.
Additional Benefits
The Blue Cross Medicare Advantage Essential (PPO) plan offers a wide range of benefits with varying cost-sharing. You'll find no copay for primary care visits, preventive services, home health services, and vision exams. The plan also covers inpatient and outpatient services, with copays ranging from $35 to $350, and covers emergency services with a $125 copay. Additional benefits include coverage for hearing, vision, and dental services, with copays for hearing exams, eyewear, and some dental procedures. The plan also covers services like ambulance, dialysis, and medical equipment with copays or coinsurance. The plan also provides an over-the-counter (OTC) allowance of $75 every three months.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $350 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you will pay a $295 copay for days 1-6, and no copay for days 7-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and additional days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services with a $350 copay, observation services with a $350 copay, and ambulatory surgical center (ASC) services with a $250 copay. Outpatient substance abuse services have a $75 copay for both individual and group sessions, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Cross Medicare Advantage Essential (PPO) plan, and requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Cross Medicare Advantage Essential (PPO) plan. Ground ambulance services have a $225 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 are covered, with a $125 copay and no coinsurance. Urgently Needed Services are covered, with a $50 copay and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage are covered, with a $125 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Cross Medicare Advantage Essential (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $35 copay, and mental health specialty services with a $30 copay for individual or 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 $40 copay. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services include an annual physical exam with no copay, and additional preventive services are covered. Some additional preventive services, like health education, in-home safety assessment, personal emergency response system, medical nutrition therapy, and others, are not covered.
Hearing Services See details
Hearing exams are covered with a $40 copay, while routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner, outer, and over-the-ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision Services include eye exams with no copay, and eyewear with a $35 copay. Eyewear includes contact lenses, eyeglass lenses, and eyeglass frames, all with no copay, but eyeglass frames are limited to one per year with a combined maximum of $100 per year for all eyewear. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
The Blue Cross Medicare Advantage Essential (PPO) plan covers some dental services, including oral exams with no copay, dental x-rays with no copay, and prophylaxis (cleaning) with no copay. Fluoride treatment and orthodontics are not covered, while endodontics, prosthodontics (removable/fixed), maxillofacial prosthetics, and implant services are offered as optional, supplemental benefits, and restorative services have no coinsurance. Oral and maxillofacial surgery has a 20% coinsurance, while adjunctive general services have a 50% coinsurance, and periodontics has a 20% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by the Blue Cross Medicare Advantage Essential (PPO) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetics/Medical Supplies and Diabetic Supplies have a 20% coinsurance, and Diabetic Supplies have a 0-20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services and radiological services, are covered. Diagnostic Procedures/Tests have a copay between $0 and $100, Lab Services have a $5 copay, Diagnostic Radiological Services have a copay up to $300, Therapeutic Radiological Services have a $45 copay, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Blue Cross Medicare Advantage Essential (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 not the sub-services: Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required, and the copay is listed separately.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Cross Medicare Advantage Essential (PPO) plan. There is no copay for days 1-20 and days 60-100, and a $214 copay for days 21-59. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for over-the-counter (OTC) items, with a maximum benefit of $75 every three months, and the plan also offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit, but acupuncture, meal benefits, Dual Eligible SNPs, and several other services are not covered. There is no copay or coinsurance for the OTC items.
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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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