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You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Medicare Advantage PPO members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Medicare Advantage Plan Notice:
HMO and HMO POS plans available in Atascosa, Bandera, Bastrop, Bexar, Burnet, Caldwell, Cameron, Chambers, Comal, El Paso, Fort Bend, Hardin, Harris, Hays, Hidalgo, Jefferson, Kendall, Lee, Liberty, Medina, Montgomery, Orange, Webb, Willacy, Williamson and Wilson counties.
PPO plans available in Bastrop, Bexar, Burnet, Caldwell, Chambers, Collin, Dallas, Denton, Fayette, Fort Bend, Hardin, Harris, Hays, Jefferson, Lee, Liberty, Montgomery, Tarrant, Travis and Williamson counties.
Plans provided by Blue Cross and Blue Shield of Texas, which refers to HCSC Insurance Services Company (HISC) (PPO plans), and GHS Insurance Company (GHS) (HMO and HMO-POS plans). HISC and GHS are Independent Licensees of the Blue Cross and Blue Shield Association. HISC and GHS are Medicare Advantage organizations with a Medicare contract. Enrollment in HISC's and GHS' plans depends on contract renewal.