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Blue Cross Medicare Advantage Dental Premier (PPO) - H4801-016-000

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

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$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

CoverageDetails
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 visit
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $30.00
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 transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules

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).

CoverageDetails
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 monitoring
Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
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-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $100.00
Copayment for Medicare-covered Lab Services $0.00 to $50.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $300.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $100.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
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/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $375.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $370.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $300.00
Prior Authorization Required for Ambulatory Surgical Center Services
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 services
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $75.00
Skilled Nursing Facility (SNF) care
Out-of-Network:
$250.00 per day for days 1 to 999

Dental Benefits

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

CoverageDetails
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

CoverageDetails
Vision care
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.

CoverageDetails
Hearing careIn-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.

CoverageDetails
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

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

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