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Blue Cross Medicare Advantage Saver (HMO)
H9706 - 008 - 0
(3 / 5)
Blue Cross Medicare Advantage Saver (HMO) is a Medicare Advantage (Part C) Plan by Blue Cross and Blue Shield of Texas.
This page features plan details for 2023 Blue Cross Medicare Advantage Saver (HMO) H9706 – 008 – 0 available in Texas.
IMPORTANT: This page has been updated with plan and premium data for 2023.
Locations
Blue Cross Medicare Advantage Saver (HMO) is offered in the following locations.
Plan Overview
Blue Cross Medicare Advantage Saver (HMO) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross and Blue Shield of Texas |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,900 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Blue Cross Medicare Advantage Saver (HMO) ?
Get help from a licensed Medicare agent.
Click to Call 1-877-354-4611 TTY 711. Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Blue Cross Medicare Advantage Saver (HMO) qualifies for a monthly Medicare Give Back Benefit of $50.00.
| Premium Reduction: | $50.00 |
Premium Breakdown
Blue Cross Medicare Advantage Saver (HMO) 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 |
|---|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $50.00 | $114.90 |
- 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 Saver (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| 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 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $43.40 | $34.80 | $26.30 | $17.70 |
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 $4,660.00. 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) | $5.00 copay | $20.00 copay | $5.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $44.00 copay | $47.00 copay | $44.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $85.00 copay | $100.00 copay | $85.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
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) | $15.00 copay | $60.00 copay | $15.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $132.00 copay | $141.00 copay | $132.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $255.00 copay | $300.00 copay | $255.00 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 $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
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 $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Blue Cross Medicare Advantage Saver (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | Not covered (no limits) |
| Extractions: | 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Non-routine services: | 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Periodontics: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | 0% coinsurance (limits may apply) (authorization not required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0-250 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0-100 copay (authorization required) (referral required) |
| Lab services: | $0-50 copay (authorization required) (referral required) |
| Outpatient x-rays: | $0-100 copay (authorization required) (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $30 copay per visit (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $40 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $35 copay (authorization required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $275 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (no limits) (authorization not required) (referral not required) |
| Hearing aids: | $699-999 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | $35 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| $370 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral required) |
Hospital coverage (outpatient)
| $275 copay per visit (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $6,900 In-network |
Medical equipment/supplies
| Diabetes supplies: | 0-20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $250 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral required) |
| Outpatient group therapy visit: | $35 copay (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | $35 copay (authorization required) (referral required) |
| Outpatient individual therapy visit: | $35 copay (authorization required) (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | $35 copay (authorization required) (referral required) |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $35 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $35 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $196 per day for days 21 through 59 $0 per day for days 60 through 100 (authorization required) (referral required) |
Transportation
| Not covered |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | Not covered (no limits) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $39.10 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Blue Cross Medicare Advantage Saver (HMO) ?
Get help from a licensed Medicare agent.
Click to Call 1-877-354-4611 TTY 711. Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.