Blue Cross Medicare Advantage Choice Plus (PPO)


Medicare Plan Details

2020 Plan
Monthly Premium
(select county for price)

 

by Blue Cross and Blue Shield of Texas
Additional Coverage
Vision Dental
Overall Government Star Rating
 3.5
out of 5 stars

State: Texas

Select your county to view the price for this plan

 


Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$750 annual deductible
$10,000 In and Out-of-network
$6,700 In-network
$10,000 Out-of-network
No
No
Yes
Yes

Medical Benefits

Doctor Services

In-network: $10 per visit
Out-of-network: 50% per visit
In-network: $50 per visit
Out-of-network: 50% per visit

Tests, labs, & imaging

In-network: $0-100
Out-of-network: 50%
In-network: $5-50
Out-of-network: 50%
In-network: $275-325
Out-of-network: 50%
In-network: $5-100
Out-of-network: 50%
$90 per visit (always covered)
$40 per visit (always covered)

Hospital Services

In-network: $372 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: 50% per stay
In-network: $325 per visit
Out-of-network: 50% per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$178 per day for days 21 through 100
Out-of-network: 50% per stay

Preventive services

In-network: $0 copay
Out-of-network: 50%

Ambulance

In-network: $300
Out-of-network: $300

Therapy services

In-network: $40
Out-of-network: 50%
In-network: $40
Out-of-network: 50%

Mental health services

In-network: $30
Out-of-network: 50%
In-network: $30
Out-of-network: 50%
In-network: $30
Out-of-network: 50%
In-network: $30
Out-of-network: 50%

Opioid treatment services

Covered

Other services

In-network: 20% per item
Out-of-network: 20% per item
In-network: 20% per item
Out-of-network: 20% per item
In-network: 0-20% per item
Out-of-network: 20% per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phase1Catastrophic coverage phase
Preferred Generic$5.00 copay$5.00 copay


Generic drugs :
$3.60 copay or 5% (whichever costs more)

Brand-name drugs :
$8.95 copay or 5% (whichever costs more)

Generic$19.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug
Specialty Tier25%
1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.

Part B Drugs

In-network: 20%
Out-of-network: 50%
In-network: 20%
Out-of-network: 50%

Extra Benefits

Hearing

In-network: $50
Out-of-network: 50%
Not covered
Not covered
Not covered
Not covered

Preventive Dental

Covered under office visit
Covered under office visit
Not covered
Covered under office visit

Comprehensive dental

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Vision

In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Not covered
Not covered
Not covered
Not covered
Limited coverage
Not covered
 3.5
 4
 3
 2
 4
 3
 3.5
 4
 4
 1
 4

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