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Blue Cross Medicare Advantage Optimum (PPO) - H0107-004-000
$128.00
Monthly Premium
Blue Cross Medicare Advantage Optimum (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H0107-004-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$128.00
Monthly Premium
Montana 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 Montana Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price. Speak with a licensed insurance agent to review plans available to you at 1-800-557-6059 (TTY 711,24/7).
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $128.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $4,175.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $75 |
| Inpatient hospital care | In-Network: Acute Hospital Services: $275 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $25 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $120 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $290 Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
Blue Cross Medicare Advantage Optimum (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Optimum (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20 Prior Authorization Required for Chiropractic Services Only chiropractic services related to the subluxation of the spine require authorization. |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable medical equipment (DME) | Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $200 Copayment for Medicare Covered Lab Services $200 Copayment for Medicare Covered Diagnostic Radiological Services $0 to $400 Coinsurance for Medicare Covered Therapeutic Radiological Services 35% Copayment for Medicare Covered Outpatient X-Ray Services $200 ($0 copay for the Diagnostic Bone Mass Measurement and Diagnostic Colonoscopy test performed on the same date of service as the corresponding preventive test. All other services are covered at a $50 copay.) |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $324 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $50 Copayment for Medicare Covered Group Sessions $50 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $275 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $225 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $100 Copayment for Medicare Covered Group Sessions $100 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
$50/qtrly (Note: Unused OTC amounts roll over from quarter to quarter, but do not roll over to the next calendar year. Members may use their pre-loaded card on select OTC item(s) from plan approved catalog and item(s) are shipped to members. Additionally, members may use their pre-loaded card at select retail stores for select OTC items. Only the amount allocated for OTC items may be used on the pre-loaded card. No cash is exchanged.) |
| Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $75 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 39 $0 per day for days 40 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
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 | Out-of-Network: Medicare Covered Preventive Dental Services: Copayment for Medicare Covered Preventive Dental $75 |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $75 Copayment for Medicare Covered Eyewear $75 |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $75 |
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 Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing Montana 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 Montana 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 |
Montana Counties Served
- Beaverhead
- Big Horn
- Broadwater
- Carbon
- Cascade
- Chouteau
- Custer
- Deer Lodge
- Divide
- Fergus
- Flathead
- Gallatin
- Glacier
- Golden Valley
- Granite
- Hill
- Idaho
- Jefferson
- Judith Basin
- Lake
- Lewis And Clark
- Liberty
- Lincoln
- Madison
- Mckenzie
- Meagher
- Mineral
- Missoula
- Musselshell
- Park
- Pondera
- Powell
- Ravalli
- Rosebud
- Sanders
- Silver Bow
- Stillwater
- Sweet Grass
- Teton
- Toole
- Wheatland
- Yellowstone
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.