Blue Cross Medicare Advantage Flex (PPO) H4801-014-000 2024 Plan Details and Costs

Texas Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Texas Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$238.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$545.00
Out-of-pocket maximum	($1.00)
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00
Specialty doctor visit	Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 0%
Inpatient hospital care	In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $0.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00
Emergency room visit	Emergency Care: Copayment for Emergency Care $0.00 Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00
Ambulance transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Flex (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Flex (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 0%
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 0%
Durable medical equipment (DME)	Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 0%
Diagnostic tests, lab and radiology services, and X-rays	Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 0% Coinsurance for Medicare Covered Lab Services 0% Coinsurance for Medicare Covered Diagnostic Radiological Services 0% Coinsurance for Medicare Covered Therapeutic Radiological Services 0% Coinsurance for Medicare Covered Outpatient X-Ray Services 0%
Home health care	In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services
Mental health inpatient care	In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0.00 Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery	Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0%
Outpatient substance abuse care	In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0.00 Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	Out-of-Network: Copayment for Skilled Nursing Facility Services per Stay $0.00

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Dental care	In-Network: Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Vision benefits	Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 0% Coinsurance for Medicare Covered Eyewear 0% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 0%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing benefits	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00 Maximum 1 visit every year Copayment for Fitting/Evaluation for Hearing Aid $0.00 Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00 Maximum 2 Hearing Aids every year

Coverage

Details

Hearing benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00

Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00

Maximum 2 Hearing Aids every year

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Preventive services and health/wellness education programs	Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0%

Prescription Drug Costs and Coverage

The Blue Cross Medicare Advantage Flex (PPO) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tiers 1 and 2)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$545.00 (excludes Tiers 1 and 2)
Tier 1	Preferred retail $0.00 Standard retail $15.00 Preferred mail order $0.00 Standard mail order $15.00
Tier 2	Preferred retail $8.00 Standard retail $20.00 Preferred mail order $8.00 Standard mail order $20.00
Annual drug deductible	$545.00 (excludes Tiers 1 and 2)
Tier 1	Preferred retail $0.00 Standard retail $30.00 Preferred mail order $0.00 Standard mail order $30.00
Tier 2	Preferred retail $16.00 Standard retail $40.00 Preferred mail order $16.00 Standard mail order $40.00
Annual drug deductible	$545.00 (excludes Tiers 1 and 2)
Tier 1	Preferred retail $0.00 Standard retail $45.00 Preferred mail order $0.00 Standard mail order $45.00
Tier 2	Preferred retail $24.00 Standard retail $60.00 Preferred mail order $24.00 Standard mail order $60.00

When reviewing Texas Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Texas that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents	Summary of benefits Evidence of coverage Star ratings

Links to plan documents

Texas Counties Served

Anderson Andrews Aransas Archer Armstrong Austin Bailey Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Burleson Calhoun Cameron Camp Carson Cass Castro Cherokee Clay Cochran Coke Coleman Collin Concho Coryell Crane Crosby Culberson Dallam Dallas Dawson De Witt Deaf Smith Delta Denton Dickens Dimmit Donley Duval Ector Edwards El Paso Ellis Erath Falls Fisher Floyd Foard Fort Bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Grayson Gregg Grimes Hale Hall Hamilton Hansford Hardeman Harris Harrison Hartley Haskell Henderson Hidalgo Hockley Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jeff Davis Jefferson Jim Hogg Jim Wells Karnes Kaufman Kenedy Kent Kimble King Kinney Kleberg Knox La Salle Lamar Lamb Lavaca Leon Liberty Limestone Live Oak Loving Lubbock Lynn Madison Marion Martin Mason Maverick Mcculloch Mclennan Menard Midland Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Nueces Oldham Orange Palo Pinto Panola Parker Pecos Polk Potter Presidio Rains Randall Reagan Red River Reeves Refugio Roberts Robertson Runnels Rusk San Augustine San Jacinto San Patricio San Saba Schleicher Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Terry Throckmorton Titus Tom Green Travis Trinity Tyler Upshur Upton Uvalde Van Zandt Victoria Walker Waller Washington Webb Wheeler Willacy Williamson Winkler Wise Wood Yoakum Young Zapata Zavala

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.