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Health Care Service Corporation

Plan ID: H4801-15-0

Blue Cross Medicare Advantage Saver Plus (PPO)

2025 Blue Cross Medicare Advantage Saver Plus (PPO) H4801 — 015 — 0 is a Medicare Advantage plan with drug coverage. It has received a 3-out-of-5 star rating from CMS for 2025.

Learn more about Blue Cross Medicare Advantage Saver Plus (PPO) H4801 - 015 - 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 stars for 2025

$0.00 /mo

Monthly premium

$590.00

Drug deductible

$7550.00

Out-of-pocket maximum

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Call to enroll

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2025 Blue Cross Medicare Advantage Saver Plus (PPO) H4801 — 015 — 0 is a PPO offered in Dallas Metro Area by Health Care Service Corporation. It has a monthly premium of $0.00.

Premium Breakdown

Standard Part B Premium

$185.00

Part B premium reduction

- $0

Monthly Plan Premium

$0.00

Total Premium:

$185.00

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

Out-of-pocket maximum

$7550.00

Plan Organization:

Health Care Service Corporation

Plan Type:

PPO

Location:

Dallas Metro Area

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Drug deductible

$590

Note:

This plan does not charge an annual deductible for all drugs. The $590.00 annual deductible only applies to drugs in certain tiers.

Sign up for Blue Cross Medicare Advantage Saver Plus (PPO)

Enroll online

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Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

Blue Cross Medicare Advantage Saver Plus (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced Alternative

Prescription drug deductible

$590.00

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	-	$18.00 Copay	-	$18.00 Copay
2. Standard Generic	-	-	-	-
3. Preferred Brand	-	-	-	-
4. Non-Preferred Drug	-	-	-	-
5. Specialty Tier	-	-	-	-

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.

Additional Benefits

Blue Cross Medicare Advantage Saver Plus (PPO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Adjunctive General Services

In-Network: 50 Coins - No Co pay

Oral and Maxillofacial Surgery

In-Network: 20 Coins - No Co pay

Periodontics

In-Network: 20 Coins - No Co pay

Restorative Services

In-Network: 0 Coins - No Co pay

Preventive dental

Dental X-Rays

In-Network: No Coins - 0.00 Copay

Out-Of-Network: No Coins - 0.00 Copay

Oral Exams

In-Network: No Coins - 0.00 Copay

Out-Of-Network: No Coins - 0.00 Copay

Prophylaxis (cleaning)

In-Network: No Coins - 0.00 Copay

Out-Of-Network: No Coins - 0.00 Copay

Diagnostic procedures/lab services/imaging

Lab services

In-Network: $0-50 copay

Out-Of-Network: $30-200 copay

Outpatient x-rays

In-Network: $0-100 copay

Out-Of-Network: $30-200 copay

Diagnostic radiology services

Diagnostic tests and procedures

In-Network: $0-100 copay

Out-Of-Network: $0-200 copay

Doctor visits

Primary

In-Network: $0 copay

Out-Of-Network: $30 copay per visit

Specialist

In-Network: $35 copay per visit

Out-Of-Network: $75 copay per visit

Emergency care/Urgent care

Urgent care

$40 copay per visit (always covered)

Emergency

$110 copay per visit (always covered)

Foot care (podiatry services)

Routine foot care

Not covered

Foot exams and treatment

In-Network: $40 copay

Out-Of-Network: $75 copay

Ground ambulance

All service types

In-Network: $275 copay

Out-Of-Network: $275 copay

Hearing

Fitting/evaluation

In-Network: $0 copay

Out-Of-Network: $0 copay

Medicare-Covered Hearing Exam

In-Network: $40 copay

Out-Of-Network: $75 copay

Hearing aids

In-Network: $699-999 copay

Out-Of-Network: $699-999 copay

Hearing aids OTC

Not covered

Inpatient hospital coverage

All service types

In-Network: $395 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: $500 per day for days 1 and beyond

Outpatient hospital coverage

All service types

In-Network: $375 copay per visit

Out-Of-Network: $400 copay per visit

Optional benefits

All service types

Yes

Medical equipment/supplies

Durable medical equipment

Diabetes supplies

In-Network: 0-20% coinsurance per item

Out-Of-Network: 20% coinsurance per item

Prosthetics

Medicare Part B drugs

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: 50% coinsurance

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 50% coinsurance

Mental health services

Outpatient group therapy visit

In-Network: $40 copay

Out-Of-Network: $50 copay

Outpatient individual therapy visit with a psychiatrist

In-Network: $40 copay

Out-Of-Network: $50 copay

Inpatient hospital - psychiatric

In-Network: $290 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: $500 per day for days 1 and beyond

Outpatient group therapy visit with a psychiatrist

In-Network: $40 copay

Out-Of-Network: $50 copay

Outpatient individual therapy visit

In-Network: $40 copay

Out-Of-Network: $50 copay

Preventive care

All service types

In-Network: $0 copay

Out-Of-Network: $0 copay

Rehabilitation services

Occupational therapy visit

In-Network: $35 copay

Out-Of-Network: $75 copay

Physical therapy and speech and language therapy visit

In-Network: $40 copay

Out-Of-Network: $75 copay

Skilled Nursing Facility

All service types

In-Network: $0 per day for days 1 through 20 $214 per day for days 21 through 59 $0 per day for days 60 through 100

Out-Of-Network: $250 per day for days 1 and beyond

Transportation

All service types

Not covered

Vision

Contact lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass frames

In-Network: $0 copay

Out-Of-Network: $0 copay

Other

Not covered

Routine eye exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Upgrades

Not covered

Eyeglasses (frames and lenses)

Not covered

Wellness programs (eg, fitness, nursing hotline)

All service types

Covered

Plan Providers

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.

Get Personalized Help from a licensed insurance agent

1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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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.

* 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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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.

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