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Blue Cross Medicare Advantage Basic (HMO)

H8133 - 001 - 0

(3.5 / 5)

Blue Cross Medicare Advantage Basic (HMO) is a Medicare Advantage Plan by Blue Cross and Blue Shield of Texas.

This page features plan details for 2025 Blue Cross Medicare Advantage Basic (HMO) H8133 – 001 – 0 available in Houston Metro Area.

Locations

Blue Cross Medicare Advantage Basic (HMO) is offered in the following locations.

Chambers County, Texas

Fort Bend County, Texas

Hardin County, Texas

Click to see more locations

Plan Overview

Blue Cross Medicare Advantage Basic (HMO) offers the following coverage and cost-sharing.

Insurer:	Blue Cross and Blue Shield of Texas
Health Plan Deductible:	$0
MOOP:	$4,750 In-network
Drugs Covered:	Yes

Ready to sign up for Blue Cross Medicare Advantage Basic (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Blue Cross Medicare Advantage Basic (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Blue Cross Medicare Advantage Basic (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$18.00 Copay		$18.00 Copay
2) Generic	$10.00 Copay	$20.00 Copay	$10.00 Copay	$20.00 Copay
3) Preferred Brand	$47.00 Copay	$47.00 Copay	$47.00 Copay	$47.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$36.00 Copay		$36.00 Copay
2) Generic	$20.00 Copay	$40.00 Copay	$20.00 Copay	$40.00 Copay
3) Preferred Brand	$94.00 Copay	$94.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$54.00 Copay		$36.00 Copay
2) Generic	$30.00 Copay	$60.00 Copay	$20.00 Copay	$40.00 Copay
3) Preferred Brand	$141.00 Copay	$141.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Blue Cross Medicare Advantage Basic (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: 0 Coins – No Co pay (Limits Apply)
Endodontics
- In-Network: 20 Coins – No Co pay (Limits Apply)
Maxillofacial Prosthetics
- In-Network: 20 Coins – No Co pay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: 0-20 Coins – No Co pay (Limits Apply)
Periodontics
- In-Network: 0-20 Coins – No Co pay (Limits Apply)
Prosthodontics, fixed
- In-Network: 20 Coins – No Co pay (Limits Apply)
Prosthodontics, removable
- In-Network: 20 Coins – No Co pay (Limits Apply)
Restorative Services
- In-Network: 0 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – 0.00 Copay
Oral Exams
- In-Network: No Coins – 0.00 Copay
Prophylaxis (cleaning)
- In-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

Outpatient x-rays
- $0-100 copay (Authorization Required, Referral Required)
Diagnostic radiology services (e.g., MRI)
- $0-300 copay (Authorization Required, Referral Required)
Lab services
- $0-50 copay (Authorization Required, Referral Required)
Diagnostic tests and procedures
- $0-100 copay (Authorization Required, Referral Required)

Doctor visits

Primary
- $0 copay
Specialist
- $17 copay per visit (Authorization Required, Referral Required)

Emergency care/Urgent care

Urgent care
- $40 copay per visit (always covered)
Emergency
- $125 copay per visit (always covered)

Foot care (podiatry services)

Routine foot care
- Not covered
Foot exams and treatment
- $35 copay (Authorization Required, Referral Required)

Ground ambulance

- $295 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Fitting/evaluation
- $0 copay
Hearing aids
- $699-999 copay (Limits Apply)
Medicare-Covered Hearing Exam
- $35 copay

Inpatient hospital coverage

- $350 per day for days 1 through 7
  $0 per day for days 8 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $4,750 In-network

Medical equipment/supplies

Diabetes supplies
- 0-35% coinsurance per item (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance (Authorization Required)
Other Part B drugs
- 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient group therapy visit
- $35 copay (Authorization Required, Referral Required)
Outpatient individual therapy visit
- $35 copay (Authorization Required, Referral Required)
Inpatient hospital – psychiatric
- $295 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required, Referral Required)
Outpatient group therapy visit with a psychiatrist
- $35 copay (Authorization Required, Referral Required)
Outpatient individual therapy visit with a psychiatrist
- $35 copay (Authorization Required, Referral Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $325 copay per visit (Authorization Required, Referral Required)

Preventive care

- $0 copay

Rehabilitation services

Occupational therapy visit
- $35 copay (Authorization Required, Referral Required)
Physical therapy and speech and language therapy visit
- $35 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $214 per day for days 21 through 39
  $0 per day for days 40 through 100 (Authorization Required, Referral Required)

Transportation

- $0 copay (Limits Apply, Authorization Required)

Vision

Contact lenses
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- Not covered
Eyeglass frames
- $0 copay (Limits Apply)
Routine eye exam
- $0 copay (Limits Apply)
Upgrades
- Not covered
Eyeglass lenses
- $0 copay (Limits Apply)
Other
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered