Blue Cross Medicare Advantage Essential (PPO)
Medicare Advantage Plan H8634-012 • 2026 • Bureau County, IL
Blue Cross Medicare Advantage Essential (PPO) Medicare Advantage Plan H8634-012 • 2026 • Bureau County, IL
Blue Cross Medicare Advantage Essential is a Medicare Advantage PPO plan offered by Blue Cross and Blue Shield of IL, NM, OK, TX for the 2026 plan year. It is identified by CMS Plan ID H8634-012 and uses a Preferred Provider Organization (PPO) provider network. The plan comes with prescription drug coverage.
Blue Cross Medicare Advantage Essential Overview
Plan Overview for H8634-012-0 |
|
|---|---|
| CMS Plan ID: | H8634-012-0 |
| Plan Type: | PPO |
| Plan Year: | 2026 |
| Monthly Premium: | $0.00 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $6700.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Enhanced, $450.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Bureau County, IL |
| Enrollment (Nationwide) | 890 beneficiaries |
| Enrollment (CMS – Local) | 19 beneficiaries in Bureau County |
| Provided By: | Blue Cross and Blue Shield of IL, NM, OK, TX |
Coverage Overview for Blue Cross Medicare Advantage Essential
This MAPD PPO Medicare Advantage plan includes Medicare Part A and Part B services along with integrated prescription drug coverage. The monthly premium is $0.00, and the plan allows access to Medicare-approved providers, with lower costs when using in-network providers. The annual Part D deductible is $450.00.
Primary care visits have a $5 copay | Out-of-network: 50% coinsurance, and specialist visits come with a $67 copay | Out-of-network: 50% coinsurance. Urgent care services carry a $50 copay, and ground ambulance transportation is $225 copay | Out-of-network: $225 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $6700.00. After this limit is reached, in-network services are fully covered.
This plan is recognized by CMS under Plan ID {title_plan_id}. Cost-sharing details are outlined below.
Out-of-Pocket Costs
Blue Cross Medicare Advantage Essential includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The table below outlines the most common in-network out-of-pocket costs associated with plan H8634-012.
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $5 copay | Out-of-network: 50% coinsurance |
| Specialist: | In-network: $67 copay | Out-of-network: 50% coinsurance |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $0 copay |
| Routine chiropractic: | Not covered |
| Fitness benefits: | In-network: $0 copay | Out-of-network: $0 copay |
| Health education: | Not covered |
| Counseling services: | Not covered |
| Over-the-counter drug benefits: | Not covered |
| Health transportation (non-emergency): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: $0-$300 copay | Out-of-network: 50% coinsurance |
| Lab services: | In-network: $5 copay | Out-of-network: 50% coinsurance |
| Outpatient x-rays: | In-network: $5-$100 copay | Out-of-network: 50% coinsurance |
| Diagnostic tests and procedures: | In-network: $0-$100 copay | Out-of-network: 50% coinsurance |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $125 copay |
| Worldwide emergency care: | $125 copay |
| Urgent care: | $50 copay |
| Inpatient hospital care: | In-network: | Tier 1 | $350 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay | Out-of-network: | 50% per stay |
| Skilled Nursing Facility: | In-network: | Tier 1 | $0 per day for days 1-20 | $218 per day for days 21-59 | $0 per day for days 60-100 | Out-of-network: | 50% per stay |
| Ground ambulance: | In-network: $225 copay | Out-of-network: $225 copay |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| Outpatient individual therapy: | In-network: $30 copay | Out-of-network: 50% coinsurance |
| Outpatient group therapy: | In-network: $30 copay | Out-of-network: 50% coinsurance |
| Inpatient psychiatric hospital care: | In-network: | Tier 1 | $350 per day for days 1-6 | $0 per day for days 7-90 | $0 per stay | Out-of-network: | 50% per stay |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $40 copay | Out-of-network: 50% coinsurance |
| Occupational therapy: | In-network: $40 copay | Out-of-network: 50% coinsurance |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| Diabetes supplies: | In-network: 0%-20% coinsurance | Out-of-network: 50% coinsurance |
| Durable medical equipment: | In-network: 20% coinsurance | Out-of-network: 50% coinsurance |
| Prosthetics: | In-network: 20% coinsurance | Out-of-network: 50% coinsurance |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance | Out-of-network: 50% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance | Out-of-network: 50% coinsurance |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| Oral exam: | In-network: $0 copay | Out-of-network: $0 copay |
| Dental x-rays: | In-network: $0 copay | Out-of-network: $0 copay |
| Cleaning: | In-network: $0 copay | Out-of-network: $0 copay |
| Periodontics: | In-network: 0% coinsurance | Out-of-network: 50% coinsurance |
| Endodontics: | Not covered |
| Restorative services: | In-network: 0% coinsurance | Out-of-network: 50% coinsurance |
| Implant services: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: 50% coinsurance | Out-of-network: 50% coinsurance |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay | Out-of-network: $0 copay |
| Contact lenses: | In-network: $0 copay | Out-of-network: $0 copay |
| Eyeglass frames only: | In-network: $0 copay | Out-of-network: $0 copay |
| Eyeglass lenses only: | In-network: $0 copay | Out-of-network: $0 copay |
| Eyeglasses (frames & lenses): | Not covered |
| Upgrades: | Not covered |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| Hearing exam: | In-network: $0 copay | Out-of-network: $0 copay |
| Fitting/evaluation: | In-network: $0 copay | Out-of-network: $0 copay |
| Prescription hearing aids: | In-network: $699-$999 copay | Out-of-network: $699-$999 copay |
| OTC hearing aids: | Not covered |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | Not covered |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | Not covered |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | Not covered |
Certain preventive services are covered 100% by Blue Cross Medicare Advantage Essential as a Part B benefit.
Prescription Drug Coverage
Blue Cross Medicare Advantage Essential includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Advantage coverage.
| Basic Part D Premium: | $0.00 |
|---|---|
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $15.20 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a $450.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Blue Cross and Blue Shield of IL, NM, OK, TX starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Blue Cross Medicare Advantage Essential may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $1.00 copay | Coming soon |
| Preferred Brand | 17% coinsurance | Coming soon |
| Non-Preferred Drug | 39% coinsurance | Coming soon |
| Specialty Tier | 27% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Ratings
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
What is the monthly premium for Blue Cross Medicare Advantage Essential (PPO)?
The 2026 monthly premium is $0.00. The Medicare Part B premium is paid separately.
What is the in-network MOOP for plan H8634-012?
For 2026, the in-network maximum out-of-pocket is $6700.00. The plan pays 100% of covered in-network services beyond this amount.
What is the star rating for plan H8634-012 in 2026?
For 2026, plan H8634-012 has a CMS star rating of ★3.0 out of 5 stars.
What is the total enrollment for plan H8634-012?
Total enrollment is 890 beneficiaries based on the latest CMS data.
Is there a Part D deductible for this plan?
The Part D deductible is $450.00.
Contact Information for Blue Cross and Blue Shield of IL, NM, OK, TX
| Contact Type | Details |
|---|---|
| Website: | Blue Cross and Blue Shield of IL, NM, OK, TX Plan Page |
| New Members: | 1-877-583-8129 |
| Existing Members: | 1-877-774-8592 |
| Plan Address: | PO Box 4555 | Scranton, PA 18505 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation..
- Blue Cross and Blue Shield of IL, NM, OK, TX (official source), http://getblueil.com/mapd — Last accessed October 13, 2025
- CMS.gov, "Medicare Advantage Plan Fact Sheet" — Last accessed 25 May, 2025
- Medicare.gov, "Joining a plan" — Last accessed 25 May, 2025
- Medicare.gov, "Your coverage options" — Last accessed 25 May, 2025
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