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Blue Cross Medicare Advantage Classic (PPO) - H8634-010-000
$0.00
Monthly Premium
Blue Cross Medicare Advantage Classic (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation
Plan ID: H8634-010-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
New Mexico 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 New Mexico 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 | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $200.00 |
| Out-of-pocket maximum | $6,355.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $75.00 |
| Inpatient hospital care | Out-of-Network: $500.00 per day for days 1 to 999 |
| Urgent care | Urgent Care: Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 |
| 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 Classic (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Classic (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15.00 Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | In-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) | Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| 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 $0.00 to $200.00 Copayment for Medicare Covered Lab Services $30.00 to $200.00 Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $400.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Copayment for Medicare Covered Outpatient X-Ray Services $30.00 to $200.00 |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental health inpatient care | Out-of-Network: $500.00 per day for days 1 to 999 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 Prior Authorization Required for Outpatient Mental Health Services |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $300.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $250.00 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-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 | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $75.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $50.00 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | Out-of-Network: $250.00 per day for days 1 to 999 |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Comprehensive Dental: Copayment for Medicare-covered Benefits $40.00 |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $75.00 Copayment for Medicare Covered Eyewear $75.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Maximum Plan Benefit of $40.00 |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
|
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 |
Prescription Drug Costs and Coverage
The Blue Cross Medicare Advantage Classic (PPO) offers prescription drug coverage, with an annual drug deductible of $200.00 (excludes Tiers 1, 2, and 3)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $200.00 (excludes Tiers 1, 2, and 3) |
| Tier 1 |
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| Tier 2 |
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| Tier 3 |
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| Annual drug deductible | $200.00 (excludes Tiers 1, 2, and 3) |
| Tier 1 |
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| Tier 2 |
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| Tier 3 |
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| Annual drug deductible | $200.00 (excludes Tiers 1, 2, and 3) |
| Tier 1 |
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| Tier 2 |
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| Tier 3 |
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When reviewing New Mexico 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 New Mexico 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 |
New Mexico Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.