Blue Cross Blue Shield Ppo Copay



To Blue Cross and Blue Shield Member ID Cards A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. PPO in a Suitcase PPOB in a Suitcase No Suitcase Medicare Advantage Consumer-Directed Healthcare and Healthcare Debit Cards Introduction This guide. The Blue Cross Blue Shield Association is an association of 35 independent, locally operated Blue Cross and/or Blue Shield companies. Taking Action to Address Racial Health Disparities Learn how Blue Cross and Blue Shield companies are addressing our nation's. Arkansas Blue Cross and Blue Shield: Bronze Plan 1 PPO Coverage for: Individual/Family Plan Type: PPO 1 of 6 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. You pay a $65 emergency room copay (waived if you are admitted to the hospital or for an observation stay). Out-of-Pocket Maximum. This is the most you pay per plan year for covered health expenses before the plan pays 100 percent of covered expenses for the rest of the year. Read more about how Blue Cross of Idaho is dedicated to being the best choice for healthcare coverage at competitive prices. GeoBlue Medical Insurance for Travel Short-term and long-term international health plans are available for your urgent travel needs.

Our PPO managed health care plans provide for the payment of benefits at a higher level of coverage when the member utilizes our network of preferred providers. These network providers, including physicians, specialty care providers, hospitals, and other health care facilities and practitioners, have contracted with BCBSTX to provide health care services at negotiated rates.

If the member elects to receive care from network providers:

  • They will receive the higher level of benefits (In-Network Benefits)
  • They are not required to file claim forms — Network providers bill BCBSTX for services provided
  • They are not balance billed — Network providers will not bill for costs that are in excess of the BCBSTX allowable amount for covered services.
  • Network providers are responsible for any necessary preauthorization

If the member elects to receive care from providers outside of the network, they may choose:


ParPlan Providers

Providers participating in a direct-payment arrangement with BCBSTX

Out-of-Network Providers

Non-contracting providers

If the member elects to receive care from a ParPlan Provider, benefits for covered services are available at the lower level of benefits (Out-of-Network); however…

  • ParPlan Providers will file the member’s claim forms
  • ParPlan Providers will not bill the member for costs exceeding the BCBSTX allowable amount for covered services
  • ParPlan Providers will preauthorize necessary services

If the member elects to receive care from a non-contracting provider, benefits for covered services are available at the lower level of benefits (Out-of-Network); and…

  • Members will be required to file their own claim forms
  • Members will be responsible for amounts in excess of the BCBSTX allowable amount for non-contracting providers — which may be considerable
  • Members must preauthorize necessary services

Blue

The PPO plan is available to clients through the Blue ChoiceSM Network, one of the largest networks in Texas. Blue ChoiceSM provides:

  • Access to the national BlueCard® network when members are outside of Texas
  • Over 600 participating hospitals and facilities in Texas
  • More than 800,000 doctors and 6,000 hospitals contracting with Blue Cross and Blue Shield plans nationwide

For health care services required outside of Texas, members have access to the BlueCard national network of providers.

BCBSTX offers a variety of PPO plans with varying deductible, coinsurance and copayment amount options. All plans include an outpatient prescription drug benefit with either a three-tier or four-tier pharmacy copay design.

The three-tier pharmacy copay plan design includes three tiers of medications that are comprised of:

Cross
  • Generic Drugs
  • Preferred Brand-name Drugs
  • Non-preferred Brand-name Drugs

The four-tier pharmacy copay plan design includes four tiers of medications that are comprised of:

  • Generic
  • Preferred Brand-name Drugs
  • Non-preferred Brand-name / Preferred Specialty
  • Non-preferred Specialty Drugs

Prescription drugs are available through retail pharmacies throughout Texas and mail order pharmacy services.

For more detailed information on available benefit designs, a description of the services and supplies that are covered, a listing of those services and supplies that are limited or excluded, terms and general administration or for any questions you may have regarding our products and services, contact us for the phone number of the regional sales office near you.


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Blue Cross Medicare Advantage Choice Plus (PPO) H1666-006 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Blue Cross and Blue Shield of Texas available to residents in Texas. This plan includes additional Medicare prescription drug (Part-D) coverage. The Blue Cross Medicare Advantage Choice Plus (PPO) has a monthly premium of $0 and has an in-network Maximum Out-of-Pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out of pocket. This can be a extremely nice safety net.

Blue Cross Medicare Advantage Choice Plus (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of 'preferred' providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Blue Cross and Blue Shield of Texas works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Cross Medicare Advantage Choice Plus (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of Texas and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Blue Cross and Blue Shield of Texas except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



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2021 Blue Cross and Blue Shield of Texas Medicare Advantage Plan Costs

Name:
Plan ID:
H1666-006
Provider:Blue Cross and Blue Shield of Texas
Year:2021
Type: Local PPO
Monthly Premium C+D: $0
Part C Premium: $0
MOOP: $7,550
Part D (Drug) Premium: $0
Part D Supplemental Premium $0
Total Part D Premium: $0
Drug Deductible: $445.0
Tiers with No Deductible:1
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan:H1666-008

Blue Cross Medicare Advantage Choice Plus (PPO) Part-C Premium

Blue Cross and Blue Shield of Texas plan charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.


H1666-006 Part-D Deductible and Premium

Blue Cross Medicare Advantage Choice Plus (PPO) has a monthly drug premium of $0 and a $445.0 drug deductible. This Blue Cross and Blue Shield of Texas plan offers a $0 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0 this Premium covers any enhanced plan benefits offered by Blue Cross and Blue Shield of Texas above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.


Blue Cross and Blue Shield of Texas Gap Coverage

In 2021 once you and your plan provider have spent $4130 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Blue Cross and Blue Shield of Texas plan does offer additional coverage through the gap.


H1666-006 Formulary or Drug Coverage

Blue Cross Medicare Advantage Choice Plus (PPO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.



2021 Blue Cross Medicare Advantage Choice Plus (PPO) Summary of Benefits



Additional Benefits


No


Comprehensive Dental


Diagnostic servicesNot covered
EndodonticsNot covered
ExtractionsNot covered
Non-routine servicesNot covered
PeriodonticsNot covered
Prosthodontics, other oral/maxillofacial surgery, other servicesNot covered
Restorative servicesNot covered


Deductible


$750 annual deductible


Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI)50% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)$300-325 copay
Diagnostic tests and procedures50% coinsurance (Out-of-Network)
Diagnostic tests and procedures$0-100 copay
Lab services$5-50 copay
Lab services50% coinsurance (Out-of-Network)
Outpatient x-rays50% coinsurance (Out-of-Network)
Outpatient x-rays$5-100 copay


Doctor Visits


Primary50% coinsurance per visit (Out-of-Network)
Primary$20 copay per visit
Specialist$50 copay per visit
Specialist50% coinsurance per visit (Out-of-Network)


Emergency care/Urgent Care


Emergency$90 copay per visit (always covered)
Urgent care$40 copay per visit (always covered)


Foot Care (podiatry services)


Blue cross blue shield ppo coverage
Foot exams and treatment$45 copay
Foot exams and treatment50% coinsurance (Out-of-Network)
Routine foot careNot covered

Blue Cross Blue Shield Ppo Copay



Ground Ambulance


$300 copay (Out-of-Network)
$300 copay


Hearing


Fitting/evaluationNot covered
Hearing aids - inner earNot covered
Hearing aids - outer earNot covered
Hearing aids - over the earNot covered
Hearing exam$50 copay
Hearing exam50% coinsurance (Out-of-Network)


Inpatient Hospital Coverage


$372 per day for days 1 through 5
$0 per day for days 6 through 90
50% per stay (Out-of-Network)


Medical Equipment/Supplies


Diabetes supplies20% coinsurance per item (Out-of-Network)
Diabetes supplies0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item


Medicare Part B Drugs


Chemotherapy50% coinsurance (Out-of-Network)
Chemotherapy20% coinsurance
Other Part B drugs50% coinsurance (Out-of-Network)
Other Part B drugs20% coinsurance


Mental Health Services


Inpatient hospital - psychiatric50% per stay (Out-of-Network)
Inpatient hospital - psychiatric$270 per day for days 1 through 6
$0 per day for days 7 through 90
Outpatient group therapy visit50% coinsurance (Out-of-Network)
Outpatient group therapy visit$30 copay
Outpatient group therapy visit with a psychiatrist$30 copay
Outpatient group therapy visit with a psychiatrist50% coinsurance (Out-of-Network)
Outpatient individual therapy visit$30 copay
Outpatient individual therapy visit50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist$30 copay
Outpatient individual therapy visit with a psychiatrist50% coinsurance (Out-of-Network)


MOOP


$11,300 In and Out-of-network
$7,550 In-network
$11,300 Out-of-network


Option


No


Optional supplemental benefits


No


Outpatient Hospital Coverage


50% coinsurance per visit (Out-of-Network)
$325 copay per visit


Preventive Care

Blue Cross Blue Shield Ppo Copay
$0 copay
50% coinsurance (Out-of-Network)


Preventive Dental


CleaningNot covered
Dental x-ray(s)Not covered
Fluoride treatmentNot covered
Oral examNot covered


Rehabilitation Services


Occupational therapy visit50% coinsurance (Out-of-Network)
Occupational therapy visit$40 copay
Physical therapy and speech and language therapy visit50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit$40 copay


Skilled Nursing Facility


50% per stay (Out-of-Network)
$0 per day for days 1 through 20
$184 per day for days 21 through 100


Transportation


Not covered


Vision


Contact lensesNot covered
Eyeglass framesNot covered
Eyeglass lensesNot covered
Eyeglasses (frames and lenses)Not covered
OtherNot covered
Routine eye exam$0 copay
Routine eye exam$0 copay (Out-of-Network)
UpgradesNot covered


Wellness Programs (e.g. fitness nursing hotline)


Covered

Reviews for Blue Cross Medicare Advantage Choice Plus (PPO) H1666


2019 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing

Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment
Blue Cross Blue Shield Ppo Copay

Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy

Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination

Member Complaints and Changes in Blue Cross Medicare Advantage Choice Plus (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement
Timely Decisions About Appeals

Health Plan Customer Service Rating for Blue Cross Medicare Advantage Choice Plus (PPO)

Total Customer Service Rating
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language

Blue Cross Medicare Advantage Choice Plus (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language
Appeals Auto
Appeals Upheld

Ratings For Member Complaints and Changes in the Drug Plans Performance

Blue Cross Blue Shield Ppo Deductible Texas

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement

Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs

Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


Ready to Enroll?


Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST



Coverage Area for Blue Cross Medicare Advantage Choice Plus (PPO)

(Click county to compare all available Advantage plans)

State: Texas
County:Chambers,Colorado,Fort Bend,Galveston,Hardin,
Harris,Jefferson,Liberty,Matagorda,
Montgomery,Wharton,

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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.Includes 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.