Blue Cross Medicare Advantage Flex (PPO)
H4801 - 014 - 0
(3 / 5)
Blue Cross Medicare Advantage Flex (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 Flex (PPO) H4801 – 014 – 0 available in Texas.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Blue Cross Medicare Advantage Flex (PPO) is offered in the following locations.
Plan Overview
Blue Cross Medicare Advantage Flex (PPO) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross and Blue Shield of OK, TX |
| Health Plan Deductible: | $0.00 |
| MOOP: | $0 In and Out-of-network $0 In-network $0 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.
Ready to sign up for Blue Cross Medicare Advantage Flex (PPO) ?
Premium Breakdown
Blue Cross Medicare Advantage Flex (PPO) has a monthly premium of $238.00. 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 | $198.90 | $39.10 | $0.00 | $412.70 |
- 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 Flex (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 D | LIS Full |
|---|---|
| $39.10 | $ |
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.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
| 2 (Generic) | $8.00 copay | $20.00 copay | $8.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | $47.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | $100.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 25% | 25% | 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
| 2 (Generic) | $24.00 copay | $60.00 copay | $24.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $141.00 copay | $141.00 copay | $141.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | $300.00 copay | $300.00 copay |
| 5 (Specialty Tier) |
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.
30 Day
90 Day
30 Day
90 Day
| 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 Flex (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $0 In and Out-of-network $0 In-network $0 Out-of-network |
| Yes |
| In-network | No |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Specialist | $0 copay (Authorization is required.) (Referral is not required.) |
| 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 | $0 copay (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $0 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.) |
| Oral exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Cleaning | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| 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.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network | $0 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $0 copay (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | $0 copay (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | $0 copay (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | $0 copay (Authorization is required.) (Not applicable.) |
| In-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $0 copay per stay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $0 copay per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $42.80 |
| Deductible | nan |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $55.20 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $55.20 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $55.20 |
| Eyewear: | Deductible: | N/A |
| Hearing exam: | Monthly Premium: | $55.20 |
| Hearing exam: | Deductible: | N/A |
| Hearing aids: | Monthly Premium: | $55.20 |
| Hearing aids: | Deductible: | N/A |
Ready to sign up for Blue Cross Medicare Advantage Flex (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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