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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 2026, 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 2026 to people living in OK $Mid 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 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 $97.00. 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 $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 includes an annual drug deductible of $450. For Tier 1 preferred generic drugs, members pay no copay when using a preferred pharmacy or preferred mail-order service. Tier 2 generic drugs are also cost-effective, with copays starting at just $1.00 for a one-month supply at preferred pharmacies and mail-order services. For brand-name and specialty medications, the plan uses coinsurance rather than flat copays. Tier 3 preferred brands require 17% coinsurance at preferred pharmacies and 19% at standard pharmacies, while Tier 4 non-preferred drugs carry a 38% to 40% coinsurance. Specialty Tier 5 drugs require a 27% coinsurance for a one-month supply regardless of whether you use a preferred or standard pharmacy.
Additional Benefits
The Blue Cross Medicare Advantage Balance (PPO) plan offers comprehensive medical coverage with no copay for primary care visits, preventive care, and home health services. For other medical needs, members pay predictable copays, including a $44 copay for specialists, a $120 copay for emergency room visits, and a $325 daily copay for the first six days of an inpatient hospital stay. Outpatient surgery and diagnostic services are also covered, typically featuring no coinsurance and low-to-moderate copayments. In addition to core medical care, this plan includes valuable dental, vision, and hearing benefits, offering routine exams, cleanings, and eye exams with no copay. Prescription hearing aids and eyewear are partially covered with specific copayments, while durable medical equipment and dialysis require a 20% coinsurance. Members also benefit from an over-the-counter allowance of $25 every three months with no copay or coinsurance.
Inpatient Hospital See details
Blue Cross Medicare Advantage Balance (PPO) offers inpatient acute hospital coverage with no coinsurance and a $325 daily copay for days 1 to 6, and no copay for days 7 and beyond. Inpatient psychiatric stays are covered with no coinsurance and a $225 daily copay for days 1 to 7, then no copay for days 8 to 90, while upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Blue Cross Medicare Advantage Balance (PPO) covers outpatient services with no coinsurance, featuring a $0 to $325 copay for outpatient hospital services and a $325 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $75 copay and no coinsurance.
Partial Hospitalization See details
Blue Cross Medicare Advantage Balance (PPO) covers partial hospitalization services with a $55 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Blue Cross Medicare Advantage Balance (PPO) covers ambulance services with prior authorization, requiring a $250 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Transportation services are not covered.
Emergency Services See details
Blue Cross Medicare Advantage Balance (PPO) covers emergency services with a $120 copay and no coinsurance, which is waived if admitted to the hospital within three days, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency and urgent care are partially covered with a $120 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Blue Cross Medicare Advantage Balance (PPO) provides primary care and telehealth services with no copay and no coinsurance, while specialist visits require a $44 copay and no coinsurance. Covered physical, occupational, psychiatric, and mental health therapies range from a $30 to $40 copay with no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by Blue Cross Medicare Advantage Balance (PPO) with no copay and no coinsurance for covered services, including annual physicals, fitness benefits, and kidney disease education. However, several supplemental services are not covered under this plan, such as health education, weight management programs, in-home safety assessments, and personal emergency response systems.
Hearing Services See details
Blue Cross Medicare Advantage Balance (PPO) covers hearing services with no deductible, offering routine exams and fitting evaluations with no copay and no coinsurance, and Medicare-covered exams for a $40 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $699 to $999 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 Balance (PPO) vision services are partially covered, offering eye exams with no copay and no coinsurance, and eyewear with a $35 copay and no coinsurance. While routine eye exams, contact lenses, eyeglass lenses, and frames are covered, other eye exam services, upgrades, and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Blue Cross Medicare Advantage Balance (PPO) partially covers dental services, offering Medicare-covered dental care with a $35 copay and no coinsurance, as well as routine exams, cleanings, and x-rays with no copay and no coinsurance. However, fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Blue Cross Medicare Advantage Balance (PPO) covers home infusion bundled services with no copay and no coinsurance, subject to prior authorization and step therapy. Under this benefit, Part B chemotherapy and other drugs require no copay and no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Blue Cross Medicare Advantage Balance (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Blue Cross Medicare Advantage Balance (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic shoes, with no copay and a 20% coinsurance, subject to prior authorization. Diabetic supplies are also covered with no copay and a coinsurance ranging from 0% to 20% from specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Blue Cross Medicare Advantage Balance (PPO) with no coinsurance, though prior authorization is required. Outpatient x-rays have no copay, lab services require a $5 copay, diagnostic procedures range from a $0 to $100 copay, and therapeutic radiological services have a minimum copay of $45.
Home Health Services See details
Blue Cross Medicare Advantage Balance (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Blue Cross Medicare Advantage Balance (PPO) covers some cardiac rehabilitation services with no coinsurance and prior authorization, but several specific services are not covered. Specifically, cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($30 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Blue Cross Medicare Advantage Balance (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and requires no prior three-day hospital stay, though prior authorization is required. There is no copay for days 1 through 20 and days 50 through 100, but a $218 daily copay applies for days 21 through 49, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Blue Cross Medicare Advantage Balance (PPO), which includes over-the-counter (OTC) items with no copay and no coinsurance up to $25 every three months. Acupuncture, meal benefits, and naloxone coverage are not covered under this benefit.
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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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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