Blue Cross Medicare Advantage Flex (PPO) H4801-013-000 2024 Plan Details and Costs

Oklahoma 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 Oklahoma 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	$202.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$545.00
Out-of-pocket maximum	($1.00)
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	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care	In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $0.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00
Emergency room visit	Emergency Care: Copayment for Emergency Care $0.00 Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00
Ambulance transportation	Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 0% Coinsurance for Medicare Covered Ambulance Services - Air 0%

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Flex (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Flex (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 $0.00 Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring	In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 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: Copayment for Medicare-covered Durable Medical Equipment $0.00 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: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 0% Coinsurance for Medicare Covered Lab Services 0% Coinsurance for Medicare Covered Diagnostic Radiological Services 0% Coinsurance for Medicare Covered Therapeutic Radiological Services 0% Coinsurance for Medicare Covered Outpatient X-Ray Services 0%
Home health care	In-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: Copayment for Psychiatric Hospital Services per Stay $0.00
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery	Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 0%
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 0%
Podiatry services	Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 0%
Skilled Nursing Facility (SNF) care	Out-of-Network: Copayment for Skilled Nursing Facility Services per Stay $0.00

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: Coinsurance for Medicare Covered Comprehensive Dental 0%

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	In-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 $0.00

Hearing Benefits

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

Coverage	Details
Hearing benefits	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00 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: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0%

Prescription Drug Costs and Coverage

The Blue Cross Medicare Advantage Flex (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 Oklahoma 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 Oklahoma 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	Summary of benefits Evidence of coverage Star ratings

Links to plan documents

Oklahoma Counties Served

Adair Alfalfa Atoka Blaine Bryan Caddo Canadian Carter Cherokee Cleveland Coal Cotton Craig Creek Dewey Garfield Garvin Grady Grant Greer Harmon Hughes Jackson Jefferson Johnston Kay Kingfisher Kiowa Lincoln Logan Love Major Marshall Mayes Mcclain Mcintosh Murray Muskogee Noble Nowata Okfuskee Oklahoma Okmulgee Osage Pawnee Payne Pittsburg Pontotoc Pottawatomie Pushmataha Sebastian Seminole Stephens Tillman Tulsa Wagoner

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