Blue Cross Medicare Advantage Dental Premier (PPO)

H4801 - 016 - 0
3 out of 5 stars (3 / 5)

Blue Cross Medicare Advantage Dental Premier (PPO) is a Medicare Advantage (Part C) Plan by Blue Cross and Blue Shield of OK, TX.

This page features plan details for 2024 Blue Cross Medicare Advantage Dental Premier (PPO) H4801 – 016 – 0 available in Texas.

IMPORTANT: This page has been updated with plan and premium data for 2024.

Locations

Blue Cross Medicare Advantage Dental Premier (PPO) is offered in the following locations.

Plan Overview

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

Insurer:Blue Cross and Blue Shield of OK, TX
Health Plan Deductible:$750 annual deductible
MOOP:$11,300 In and Out-of-network
$6,700 In-network
$11,300 Out-of-network
Drugs Covered:Yes
Please Note:
  • This plan does not charge an annual deductible for all drugs. The $545 annual deductible only applies to drugs on certain tiers.
  • This plan's deductible only applies to out-of-network services.

Ready to sign up for Blue Cross Medicare Advantage Dental Premier (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Premium Breakdown

Blue Cross Medicare Advantage Dental Premier (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
$174.70 $0.00 $0.00 $0.00 $174.70
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 Dental Premier (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:$545.00
Initial Coverage Limit:$5,030.00
Catastrophic Coverage Limit:$8,000.00
Drug Benefit Type:Enhanced Alternative
Additional Gap Coverage:
Formulary Link: Formulary Link

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
$0.00$

NOTE:  The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.

Initial Coverage Phase

After you pay your $545.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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 Dental Premier (PPO) also provides the following benefits.

Health plan deductible

$750 annual deductible

Other health plan deductibles?

In-network No

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

$11,300 In and Out-of-network
$6,700 In-network
$11,300 Out-of-network

Optional supplemental benefits

No

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

In-network No

Outpatient hospital coverage

In-network $375 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network $400 copay per visit (Authorization is required.) (Referral is not required.)

Doctor visits

In-network Primary$0 copay (Not applicable.) (Not applicable.)
out-of-network Primary$30 copay per visit (Not applicable.) (Not applicable.)
In-network Specialist$45 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network Specialist$75 copay per visit (Authorization is required.) (Referral is not required.)

Preventive care

In-network $0 copay (Authorization is not required.) (Referral is not required.)
out-of-network $0 copay (Authorization is not required.) (Referral is not required.)

Emergency care/Urgent care

Emergency$100 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$40 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

In-network Diagnostic tests and procedures$0-100 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic tests and procedures$0-200 copay (Authorization is required.) (Referral is not required.)
In-network Lab services$0-50 copay (Authorization is required.) (Referral is not required.)
out-of-network Lab services$30-200 copay (Authorization is required.) (Referral is not required.)
In-network Diagnostic radiology services (e.g., MRI)$0-300 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic radiology services (e.g., MRI)$0-400 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient x-rays$0-100 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient x-rays$30-200 copay (Authorization is required.) (Referral is not required.)

Hearing

In-network Hearing exam$40 copay (Authorization is not required.) (Referral is not required.)
out-of-network Hearing exam$75 copay (Authorization is not required.) (Referral is not required.)
In-network Fitting/evaluation$0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.)
out-of-network Fitting/evaluation$0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.)
In-network Hearing aids$699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Hearing aids$699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Preventive dental

In-network Oral exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Oral exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Cleaning$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Cleaning$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Fluoride treatmentNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Comprehensive dental

In-network Non-routine services0% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Non-routine services50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Diagnostic servicesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Restorative services0% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Restorative services50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Endodontics20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Endodontics50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Periodontics20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Periodontics50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Extractions20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Extractions50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Prosthodontics, other oral/maxillofacial surgery, other services20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Prosthodontics, other oral/maxillofacial surgery, other services50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Vision

In-network Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
OtherNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Eyeglasses (frames and lenses)Not covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
UpgradesNot covered (Not applicable.) (Not applicable.)

Rehabilitation services

In-network Occupational therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Occupational therapy visit$75 copay (Authorization is required.) (Referral is not required.)
In-network Physical therapy and speech and language therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Physical therapy and speech and language therapy visit$75 copay (Authorization is required.) (Referral is not required.)

Ground ambulance

In-network $275 copay (Not applicable.) (Not applicable.)
out-of-network $275 copay (Not applicable.) (Not applicable.)

Transportation

Not covered (Not applicable.) (Not applicable.)

Foot care (podiatry services)

In-network Foot exams and treatment$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Foot exams and treatment$75 copay (Authorization is required.) (Referral is not required.)
Routine foot careNot covered (Not applicable.) (Not applicable.)

Medical equipment/supplies

In-network Durable medical equipment (e.g., wheelchairs, oxygen)20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen)20% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Diabetes supplies0-20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Diabetes supplies20% coinsurance per item (Authorization is required.) (Not applicable.)

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

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

In-network Chemotherapy0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy50% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs50% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs50% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network $370 per day for days 1 through 6
$0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.)
out-of-network $500 per day for days 1 and beyond (Authorization is required.) (Referral is not required.)

Mental health services

In-network Inpatient hospital – psychiatric$290 per day for days 1 through 6
$0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.)
out-of-network Inpatient hospital – psychiatric$500 per day for days 1 and beyond (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit with a psychiatrist$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit with a psychiatrist$50 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit with a psychiatrist$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit with a psychiatrist$50 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit$50 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit$50 copay (Authorization is required.) (Referral is not required.)

Skilled Nursing Facility

In-network $0 per day for days 1 through 20
$203 per day for days 21 through 59
$0 per day for days 60 through 100 (Authorization is required.) (Referral is not required.)
out-of-network $250 per day for days 1 and beyond (Authorization is required.) (Referral is not required.)

Ready to sign up for Blue Cross Medicare Advantage Dental Premier (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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