BlueCross Total Value (PPO) Medicare Advantage Plan H8003-005 • 2026 • Lexington County, SC

BlueCross Total Value Overview

Plan Overview for BlueCross Total Value

This Medicare Advantage MAPD PPO plan combines hospital, medical, and prescription drug coverage and allows access to Medicare-approved providers. The monthly premium is $0.00, and the plan includes Medicare Part A and Part B benefits along with integrated prescription drug coverage. The annual Part D deductible is $615.00.

Primary care visits have a $0 copay | Out-of-network: $40 copay, while specialist visits come with a $45 copay | Out-of-network: $55 copay. Urgent care services carry a $10 copay, and ground ambulance transportation is $350 copay | Out-of-network: $365 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $9250.00. After this limit is reached, in-network services are fully covered for the remainder of the year.

This plan is listed by CMS under Plan ID H8003-005. Cost-sharing details for key services are provided below.

Cost Sharing Expenses

Cost-sharing for BlueCross Total Value includes out-of-pocket expenses for covered healthcare services. The table below provides a summary of typical in-network out-of-pocket costs for plan H8003-005.

Certain preventive services are covered 100% by BlueCross Total Value as a Part B benefit.

Prescription Drug Coverage

BlueCross Total Value 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 Special Needs 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 Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $615.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Blue Cross Blue Shield of South Carolina starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, BlueCross Total Value may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

Medicare Plan Star Ratings

The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (Part C) and Part D prescription drug plans each year using a 5-star system. These ratings measure plan performance in areas such as preventive care, management of chronic conditions, and member experience.