Blue Cross Medicare Advantage Dental Premier (PPO)

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

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

Plan ID: H4801-016-000

$0.00 Monthly Premium

Texas 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 Texas 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$545.00
Out-of-pocket maximum$6,700.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
$370.00 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 $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 $275.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Dental Premier (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Dental Premier (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 $15.00
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)
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 careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$290.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
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 itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $50.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $40.00
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
$203.00 per day for days 21 to 59
$0.00 per day for days 60 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
Copayment for Non-routine Services $0.00
Copayment for Restorative Services $0.00
Coinsurance for Endodontics 20%
Coinsurance for Periodontics 20%
Coinsurance for Extractions 20%
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 20%
Maximum Plan Benefit of $5000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive

Vision Benefits

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

Coverage Details
Vision benefits
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
Copayment for Non-Medicare Covered Eyewear $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 benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year

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 Dental Premier (PPO) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tiers 1 and 2)

Coverage
Cost
Coverage & Cost
Annual drug deductible$545.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $15.00
  • Tier 2
  • Preferred retail $8.00
  • Standard retail $20.00
  • Preferred mail order $8.00
  • Standard mail order $20.00
  • Annual drug deductible$545.00 (excludes Tiers 1 and 2)
    Tier 1
  • Preferred retail $0.00
  • Standard retail $30.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
  • Tier 2
  • Preferred retail $16.00
  • Standard retail $40.00
  • Preferred mail order $16.00
  • Standard mail order $40.00
  • Annual drug deductible$545.00 (excludes Tiers 1 and 2)
    Tier 1
  • Preferred retail $0.00
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $45.00
  • Tier 2
  • Preferred retail $24.00
  • Standard retail $60.00
  • Preferred mail order $24.00
  • Standard mail order $60.00
  • When reviewing Texas 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 Texas 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

    Texas Counties Served

    Anderson Andrews Aransas Archer Armstrong Austin Bailey Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Burleson Calhoun Cameron Camp Carson Cass Castro Cherokee Clay Cochran Coke Coleman Collin Concho Coryell Crane Crosby Culberson Dallam Dallas Dawson De Witt Deaf Smith Delta Denton Dickens Dimmit Donley Duval Ector Edwards El Paso Ellis Erath Falls Fisher Floyd Foard Fort Bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Grayson Gregg Grimes Hale Hall Hamilton Hansford Hardeman Harris Harrison Hartley Haskell Henderson Hidalgo Hockley Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jeff Davis Jefferson Jim Hogg Jim Wells Karnes Kaufman Kenedy Kent Kimble King Kinney Kleberg Knox La Salle Lamar Lamb Lavaca Leon Liberty Limestone Live Oak Loving Lubbock Lynn Madison Marion Martin Mason Maverick Mcculloch Mclennan Menard Midland Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Nueces Oldham Orange Palo Pinto Panola Parker Pecos Polk Potter Presidio Rains Randall Reagan Red River Reeves Refugio Roberts Robertson Runnels Rusk San Augustine San Jacinto San Patricio San Saba Schleicher Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Terry Throckmorton Titus Tom Green Travis Trinity Tyler Upshur Upton Uvalde Van Zandt Victoria Walker Waller Washington Webb Wheeler Willacy Williamson Winkler Wise Wood Yoakum Young Zapata Zavala

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

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