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Blue Cross Medicare Advantage Dental Premier (PPO)

H4801 - 021 - 0
3 out of 5 stars (3 / 5)

Blue Cross Medicare Advantage Dental Premier (PPO) is a Medicare Advantage Plan by Blue Cross and Blue Shield of OK, TX.

This page features plan details for 2025 Blue Cross Medicare Advantage Dental Premier (PPO) H4801 – 021 – 0 available in Oklahoma.

Locations

Blue Cross Medicare Advantage Dental Premier (PPO) is offered in the following locations.

Adair County, Oklahoma
Alfalfa County, Oklahoma
Atoka County, Oklahoma

Click to see more locations

Plan Overview

Blue Cross Medicare Advantage Dental Premier (PPO) offers the following coverage and cost-sharing.

Insurer:Blue Cross and Blue Shield of OK, TX
Health Plan Deductible:$0
MOOP:$11,300 In and Out-of-network
$6,900 In-network
$11,300 Out-of-network
Drugs Covered:Yes

Ready to sign up for Blue Cross Medicare Advantage Dental Premier (PPO) ?

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 Dental Premier (PPO) 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 Dental Premier (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $590.00
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 DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $590.00 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.

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 Dental Premier (PPO) 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
    • Out-of-Network: No Coins – 0.00 Copay
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: $0-200 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0-100 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-300 copay (Authorization Required)
    • Out-of-Network: $0-400 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-100 copay (Authorization Required)
  • Lab services
    • In-Network: $5 copay (Authorization Required)
    • Out-of-Network: $200 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $30-200 copay (Authorization Required)

Doctor visits

  • Specialist
    • Out-of-Network: $75 copay per visit (Authorization Required)
    • In-Network: $34 copay per visit (Authorization Required)
  • Primary
    • Out-of-Network: $30 copay per visit
    • In-Network: $0 copay

Emergency care/Urgent care

  • Emergency
    • $100 copay per visit (always covered)
  • Urgent care
    • $40 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • Out-of-Network: $75 copay (Authorization Required)
    • In-Network: $40 copay (Authorization Required)

Ground ambulance

    • Out-of-Network: $250 copay
    • In-Network: $250 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • Out-of-Network: $699-999 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay
  • Hearing aids OTC
    • Not covered
  • Hearing aids
    • In-Network: $699-999 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $75 copay
  • Fitting/evaluation
    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Inpatient hospital coverage

    • In-Network: $385 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
    • Out-of-Network: $500 per day for days 1 and beyond (Authorization Required)

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

    • $11,300 In and Out-of-network
      $6,900 In-network
      $11,300 Out-of-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $290 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $50 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $50 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: $500 per day for days 1 and beyond (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $50 copay (Authorization Required)
    • In-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: $50 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: $400 copay per visit (Authorization Required)
    • In-Network: $395 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $35 copay (Authorization Required)
    • Out-of-Network: $75 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $75 copay (Authorization Required)
    • In-Network: $40 copay (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: $250 per day for days 1 and beyond (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 59
      $0 per day for days 60 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Not covered
  • Other
    • Not covered
  • Upgrades
    • Not covered
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for Blue Cross Medicare Advantage Dental Premier (PPO) ?

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

Need more information on Blue Cross Medicare Advantage Dental Premier (PPO)? See 2025 Blue Cross Medicare Advantage Dental Premier (PPO) at MedicareAdvantageRX.com.

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Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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This is a promotional communication.

Every year, Medicare evaluates plans based on a 5-star rating system.

Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.

Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

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