Health Care Service Corporation
Plan ID: H0107-11-0
2025 Blue Cross Medicare Advantage Protect (PPO) H0107 — 011 — 0 is a Medicare Advantage plan . It has received a 3.5-out-of-5 star rating from CMS for 2025.
Learn more about Blue Cross Medicare Advantage Protect (PPO) H0107 - 011 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
3.5 / 5 stars for 2025
$0.00 /mo
Monthly premium
$10000.00 / $6500.00 / $10000.00
Out-of-pocket maximum (In-Network / Out-of-Network / Combined)
Enroll online
Call to enroll
OR
Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
2025 Blue Cross Medicare Advantage Protect (PPO) H0107 — 011 — 0 is a PPO offered in Montana by Health Care Service Corporation. It has a monthly premium of $0.00 and includes a Part B premium discount of $40.00.
Standard Part B Premium
$185.00
Part B premium reduction
- $40.00
Monthly Plan Premium
$0.00
Total Premium:
$145.00
Note:
The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
No
Out-of-pocket maximum (In-Network)
$10000.00
Out-of-pocket maximum (Out-of-Network)
$6500.00
Out-of-pocket maximum (Combined)
$10000.00
Plan Organization:
Health Care Service Corporation
Plan Type:
PPO
Location:
Montana
Drugs Covered:
No
Drug Formulary:
Pharmacies:
Doctors Link:
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Blue Cross Medicare Advantage Protect (PPO) does not provide drug coverage. If drug coverage is something you need, you should consider shopping for other plans that do provide cost sharing on drugs.
Blue Cross Medicare Advantage Protect (PPO) also provides the following benefits.
Hearing Services benefits are covered.
Hearing Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Copayment
Medicare-covered Benefits, Routine Hearing Exams, Fitting/Evaluation for Hearing Aid
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Hearing Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Minimum copayment
0.00
Maximum copayment
0.00
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Minimum copayment
0.00
Maximum copayment
0.00
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Service maximum plan benefit coverage
No
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
2
Periodicity
Every year
Minimum copayment
699.00
Maximum copayment
999.00
Not covered.
Not covered.
Not covered.
Not covered.
Vision Services benefits are covered.
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eye Exams have a Copayment
Routine Eye Exams, Other
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Eyewear benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eyewear Benefits have a Copayment
Contact lenses, Eyeglasses (lenses and frames), Eyeglass frames, Upgrades
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Does the Maximum Plan Benefit Coverage amount apply to In-network services only OR does it apply to both In-network and Out-of-network services?
Both In-network and Out-of-network services
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
Yes
Combined maximum amount
100.00
Periodicity
Every year
Contact Lenses benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Not covered.
Eyeglass lenses benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every year
Eyeglass frames benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Number of eyeglass frames
1
Periodicity
Every year
Not covered.
Dental Services benefits are covered.
Medicare Dental Services benefits are covered.
Cost Sharing:
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Oral Exams benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Dental X-Rays benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Every year
Prophylaxis (Cleaning) benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Not covered.
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Does the maximum plan benefit coverage amount apply to in-network services only or does it apply to both in-network and out-of-network services
Both in-network and out-of-network services
Maximum amount
1000.00
Periodicity
Every year
Restorative Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
0
Adjunctive General Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
50
Endodontics benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Periodontics benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
20
Prosthodontics, removable benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Maxillofacial Prosthetics benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Not covered.
Prosthodontics, fixed benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Oral and Maxillofacial Surgery benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
20
Not covered.
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
Yes
Does the benefit step from?
Part B to Part D
Insulin benefits are covered.
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Is there a maximum plan benefit coverage amount?
No
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Other Defined Supplemental Benefits have a Copayment
14c4: Fitness Benefit*, 14c7: Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)*
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Memory Fitness
Minimum copayment
0.00
Maximum copayment
0.00
Not covered.
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Not covered.
Not covered.
Kidney Disease Education Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Other Preventive Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Barium Enemas, Medicare-covered Digital Rectal Exams, Medicare-covered EKG following Welcome Visit
Is a referral required for any Services?
No
Glaucoma Screening benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Diabetes Self-Management Training benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Barium Enemas benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Digital Rectal Exams benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
EKG following Welcome Visit benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Other Services benefits are covered.
Not covered.
Not covered.
Not covered.
Not covered.
Other Services benefits are covered.
More Details:
Is Authorization required for one or more Additional Services?
No
Is a referral required for one or more Additional Services?
No
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Dialysis Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment benefits are covered.
Durable Medical Equipment (DME) benefits are covered.
More Details:
Is there a coinsurance?
Yes
Minimum coinsurance
20
Maximum coinsurance
20
Is there a copayment ?
No
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Authorization required for this benefit?
Yes
Not covered.
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered.
More Details:
Is there a coinsurance?
Yes
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Diabetic Supplies and Services have a Coinsurance
Medicare-covered Diabetic Supplies, Medicare-covered Diabetic Therapeutic Shoes or Inserts
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Ambulance and Transportation Services benefits are covered.
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
Yes
Which Services have a Coinsurance
Medicare-covered Ground Ambulance Services
Is this Coinsurance waived if admitted to hospital?
No
Is there a copayment ?
Yes
Which Services have a Copayment
Medicare-covered Air Ambulance Services
Is this Copayment waived if admitted to hospital?
No
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services benefits are covered.
Not covered.
Not covered.
Outpatient Services benefits are covered.
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Observation Services benefits are covered.
Cost Sharing:
More Details:
Periodicity
Per stay
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Outpatient Substance Abuse Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
75.00
Maximum copayment
75.00
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
75.00
Maximum copayment
75.00
Outpatient Blood Services benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
More Details:
Enhanced benefit
Three (3) Pint Deductible Waived
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
Yes
Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Copayment
Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
Yes
Diagnostic Procedures/Tests benefits are covered.
More Details:
Minimum copayment
0.00
Maximum copayment
100.00
Lab Services benefits are covered.
Cost Sharing:
All Radiological Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Coinsurance
Medicare-covered Diagnostic Radiological Services, Medicare-covered X-Ray Services
Is there a copayment?
Yes
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Copayment
Medicare-covered Therapeutic Radiological Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
Yes
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Primary Care benefits are covered.
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Chiropractic Services have a Copayment
Routine Care
Not covered.
Occupational Therapy Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Minimum copayment
40.00
Maximum copayment
40.00
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Physician Specialist Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Mental Health Specialty Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
40.00
Maximum copayment
40.00
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
40.00
Maximum copayment
40.00
Not covered.
Other Health Care Professional benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
45.00
Psychiatric Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Psychiatric Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
40.00
Maximum copayment
40.00
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
40.00
Maximum copayment
40.00
Physical Therapy and Speech-Language Pathology Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
4b: Urgently Needed Services
Opioid Treatment Program Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum copayment
50.00
Maximum copayment
50.00
Home Health Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Not covered.
Not covered.
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
Emergency Services benefits are covered.
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Days
Enter number of days or hours
3
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
No
Does the cost sharing count towards any plan-level deductible?
No
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Worldwide Services have a Copayment
Worldwide Urgent Coverage, Worldwide Emergency Transportation
Is there a maximum plan benefit coverage?
No
Worldwide Emergency Coverage benefits are covered.
Cost Sharing:
Worldwide Urgent Coverage benefits are covered.
Cost Sharing:
Not covered.
Cardiac Rehabilitation Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Copayment
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Not covered.
Not covered.
Not covered.
Not covered.
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
Cost Sharing:
Days 1-20: | Days 21-59: | Days 60-100: | |
---|---|---|---|
Copayment | 0.00 | 214.00 | 0.00 |
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
No
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
No
Periodicity
Original Medicare
Not covered.
Not covered.
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
Days 1-6: | Days 7-90: | |
---|---|---|
Copayment | 370.00 | 0.00 |
More Details:
Enhanced benefits
Non-Medicare-covered Stay
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Original Medicare
Additional Days for Inpatient Hospital-Acute benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Number of day intervals for Additional Days
Zero (No Copayment per Day)
Not covered.
Not covered.
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
Days 1-6: | Days 7-90: | |
---|---|---|
Copayment | 290.00 | 0.00 |
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Original Medicare
Not covered.
Not covered.
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
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.
* 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.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved