Blue Cross Medicare Advantage Flex (PPO) is a Medicare Advantage Plan by Blue Cross and Blue Shield of OK, TX.
This page features plan details for 2024 Blue Cross Medicare Advantage Flex (PPO) H4801 – 014 – 0 available in Texas.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Blue Cross Medicare Advantage Flex (PPO) is offered in the following locations.
Blue Cross Medicare Advantage Flex (PPO) offers the following coverage and cost-sharing.
Insurer: | Blue Cross and Blue Shield of OK, TX |
Health Plan Deductible: | $0.00 |
MOOP: | $0 In and Out-of-network $0 In-network $0 Out-of-network |
Drugs Covered: | Yes |
Ready to sign up for Blue Cross Medicare Advantage Flex (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
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$174.70 | $198.90 | $39.10 | $0.00 | $ |
Blue Cross Medicare Advantage Flex (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $545.00 |
Initial Coverage Limit: | $5,030.00 |
Catastrophic Coverage Limit: | $8,000.00 |
Drug Benefit Type: | Enhanced Alternative |
Additional Gap Coverage: | |
Formulary Link: | Formulary Link |
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 |
---|---|
$39.10 | $ |
After you pay your $545.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
2 (Generic) | $8.00 copay | $20.00 copay | $8.00 copay | $20.00 copay |
3 (Preferred Brand) | $47.00 copay | $47.00 copay | $47.00 copay | $47.00 copay |
4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | $100.00 copay | $100.00 copay |
5 (Specialty Tier) | 25% | 25% | 25% | 25% |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
2 (Generic) | $24.00 copay | $60.00 copay | $24.00 copay | $60.00 copay |
3 (Preferred Brand) | $141.00 copay | $141.00 copay | $141.00 copay | $141.00 copay |
4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | $300.00 copay | $300.00 copay |
5 (Specialty Tier) |
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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.
Blue Cross Medicare Advantage Flex (PPO) also provides the following benefits.
$0 |
In-network | No |
$0 In and Out-of-network $0 In-network $0 Out-of-network |
Yes |
In-network | No |
In-network | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
In-network Specialist | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Specialist | $0 copay (Authorization is required.) (Referral is not required.) |
In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
Emergency | $0 copay (Not applicable.) (Not applicable.) |
Urgent care | $0 copay (Not applicable.) (Not applicable.) |
In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
out-of-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
In-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Oral exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Cleaning | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Upgrades | Not covered (Not applicable.) (Not applicable.) |
In-network Occupational therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Occupational therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network | $0 copay (Not applicable.) (Not applicable.) |
out-of-network | $0 copay (Not applicable.) (Not applicable.) |
Not covered (Not applicable.) (Not applicable.) |
In-network Foot exams and treatment | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Foot exams and treatment | $0 copay (Authorization is required.) (Referral is not required.) |
Routine foot care | Not covered (Not applicable.) (Not applicable.) |
In-network Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
In-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
out-of-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
out-of-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
Covered (Authorization is not required.) (Referral is not required.) |
In-network Chemotherapy | $0 copay (Authorization is required.) (Not applicable.) |
out-of-network Chemotherapy | $0 copay (Authorization is required.) (Not applicable.) |
In-network Other Part B drugs | $0 copay (Authorization is required.) (Not applicable.) |
out-of-network Other Part B drugs | $0 copay (Authorization is required.) (Not applicable.) |
In-network Part B Insulin drugs | $0 copay (Authorization is required.) (Not applicable.) |
out-of-network Part B Insulin drugs | $0 copay (Authorization is required.) (Not applicable.) |
In-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
out-of-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
In-network Inpatient hospital – psychiatric | $0 copay per stay (Authorization is required.) (Referral is not required.) |
out-of-network Inpatient hospital – psychiatric | $0 copay per stay (Authorization is required.) (Referral is not required.) |
In-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
out-of-network | $0 copay per stay (Authorization is required.) (Referral is not required.) |
Monthly Premium | $42.80 |
Deductible | nan |
Preventive dental: | Monthly Premium: | $55.20 |
Preventive dental: | Deductible: | N/A |
Comprehensive dental: | Monthly Premium: | $55.20 |
Comprehensive dental: | Deductible: | N/A |
Eyewear: | Monthly Premium: | $55.20 |
Eyewear: | Deductible: | N/A |
Hearing exam: | Monthly Premium: | $55.20 |
Hearing exam: | Deductible: | N/A |
Hearing aids: | Monthly Premium: | $55.20 |
Hearing aids: | Deductible: | N/A |
Ready to sign up for Blue Cross Medicare Advantage Flex (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 Flex (PPO)? See 2025 Blue Cross Medicare Advantage Flex (PPO) at MedicareAdvantageRX.com.
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
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SMID: MULTIPLAN_HCIHNDOGMED01PY25_M
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