Blue Cross Medicare Advantage Essential (PPO)

3 out of 5 stars* for plan year 2024
$0.00 Monthly Premium

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

Plan ID: H8634-012-000

$0.00 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$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$5,900.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $30.00
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:
$350.00 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 $120.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $225.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

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

Coverage Details
Chiropractic services
Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $75.00
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 $0.00 to $200.00
Copayment for Medicare Covered Lab Services $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
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/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $320.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $320.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250.00
Prior Authorization Required for Ambulatory Surgical Center Services
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 itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $95.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $75.00
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
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $75.00
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Coinsurance for Non-Medicare Covered Comprehensive Dental 50%

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

Eyewear:
Copayment for Medicare-Covered Benefits $35.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglass Lenses $0.00
Copayment for Eyeglass Frames $0.00
Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Hearing Benefits

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

Coverage Details
Hearing benefits
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $75.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered 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

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

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

Back to plans in Illinois

Every 60 seconds, we help someone enroll in a Medicare Advantage plan.1

Ready to find your plan?

Or call a licensed insurance agent

1-800-557-6059

TTY 711, 24/7

Or call a licensed insurance agent

  • secure website