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Blue Cross Medicare Advantage Choice Plus (PPO)

H1666 - 008 - 0
3 out of 5 stars (3 / 5)

Blue Cross Medicare Advantage Choice Plus (PPO) is a Medicare Advantage Plan by Blue Cross and Blue Shield of NM, TX.

This page features plan details for 2025 Blue Cross Medicare Advantage Choice Plus (PPO) H1666 – 008 – 0 available in San Antonio Metro Area.

Locations

Blue Cross Medicare Advantage Choice Plus (PPO) is offered in the following locations.

Atascosa County, Texas
Bandera County, Texas
Bexar County, Texas

Click to see more locations

Plan Overview

Blue Cross Medicare Advantage Choice Plus (PPO) offers the following coverage and cost-sharing.

Insurer:Blue Cross and Blue Shield of NM, TX
Health Plan Deductible:$750 annual deductible
MOOP:$14,000 In and Out-of-network
$7,400 In-network
$14,000 Out-of-network
Drugs Covered:Yes

Ready to sign up for Blue Cross Medicare Advantage Choice Plus (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Blue Cross Medicare Advantage Choice Plus (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

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

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $0.00 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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

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

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: 0 Coins – No Co pay (Limits Apply)
  • Endodontics
    • In-Network: 20 Coins – No Co pay (Limits Apply)
  • Maxillofacial Prosthetics
    • In-Network: 20 Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 0-20 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 0-20 Coins – No Co pay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: 20 Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 20 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 0 Coins – No Co pay (Limits Apply)

Diagnostic and 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: $5-50 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $5-100 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $0-400 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-100 copay (Authorization Required)
    • Out-of-Network: $0-200 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $30-200 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-300 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $30-200 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $5 copay per visit
    • Out-of-Network: $30 copay per visit
  • Specialist
    • Out-of-Network: $75 copay per visit (Authorization Required)
    • In-Network: $34 copay per visit (Authorization Required)

Emergency care/Urgent care

  • Urgent care
    • $45 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: $45 copay (Authorization Required)
    • Out-of-Network: $75 copay (Authorization Required)

Ground ambulance

    • Out-of-Network: $250 copay
    • In-Network: $250 copay

Health plan deductible

    • $750 annual deductible

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay
  • Medicare-Covered Hearing Exam
    • In-Network: $50 copay
    • Out-of-Network: $75 copay
  • Hearing aids
    • In-Network: $699-999 copay (Limits Apply)
    • Out-of-Network: $699-999 copay (Limits Apply)
  • Fitting/evaluation
    • Out-of-Network: $0 copay
  • Hearing aids OTC
    • Not covered

Inpatient hospital coverage

    • In-Network: $390 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
    • Out-of-Network: $500 per day for days 1 and beyond (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $14,000 In and Out-of-network
      $7,400 In-network
      $14,000 Out-of-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 50% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $270 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: $50 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $30 copay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $50 copay (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $50 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $30 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: $500 per day for days 1 and beyond (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $50 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $350 copay per visit (Authorization Required)
    • Out-of-Network: $400 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: $75 copay (Authorization Required)
    • In-Network: $35 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: $75 copay (Authorization Required)

Skilled Nursing Facility

    • 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 (Authorization Required)
    • Out-of-Network: $250 per day for days 1 and beyond (Authorization Required)

Transportation

    • Not covered

Vision

  • Other
    • Not covered
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Not covered
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Not covered
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Blue Cross Medicare Advantage Choice Plus (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Blue Cross Medicare Advantage Choice Plus (PPO)? See 2025 Blue Cross Medicare Advantage Choice Plus (PPO) at MedicareAdvantageRX.com.

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