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Blue Cross Medicare Advantage Choice Plus (PPO)

3.5 out of 5 stars* for plan year 2023
$77.00 Monthly Premium

Blue Cross Medicare Advantage Choice Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation

Plan ID: H8634-003-000

$77.00 Monthly Premium

Illinois Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Illinois Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$77.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$4,500.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
$295.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Choice Plus (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Choice Plus (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$200.00
Copayment for Medicare Covered Lab Services
$200.00
Copayment for Medicare Covered Diagnostic Radiological Services $400.00
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Copayment for Medicare Covered Outpatient X-Ray Services $200.00
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient care
Out-of-Network:
$500.00 per day for days 1 to 999
Mental health outpatient care
Out-of-Network:

Outpatient Mental Health Services:
Copayment for Medicare Covered Individual Sessions $50.00
Copayment for Medicare Covered Group Sessions $50.00
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $400.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $350.00
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $75.00
Copayment for Medicare-covered Group Sessions $75.00
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter items
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $70.00
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $50.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$196.00 per day for days 21 to 49
$0.00 per day for days 50 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every year

Comprehensive Dental:
Copayment for Medicare-covered Benefits $35.00

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $40.00 every year for in and out of network services combined

Eyewear:
Copayment for Medicare-Covered Benefits $35.00

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programs
Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

When reviewing Illinois Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Illinois that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Illinois Counties Served

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