Medicare Plan Lookup Official CMS data · Contract Year 2026
CMS 2026 data

2026 Medicare plan code

H0107-004-000

Blue Cross Medicare Advantage Optimum (PPO) · Blue Cross and Blue Shield of Montana · MT High PPO

Compact plan code: H0107004000

2026

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2026 plan record

Blue Cross Medicare Advantage Optimum (PPO)

H0107-004-000 MT High PPO Local PPO
Open in quick lookup
01

In-network

Inpatient hospital

Days 1–6 $350 / day
Days 7–90 $0 / day
Total of listed copays · 6 charged days $2,100
02

Emergency transport

Ambulance

Ground · in-network$290 copay
Air · in-network20% coinsurance
03

Emergency services

Emergency room

$120 copay

Waived if admitted

04

Medical maximum

Maximum out-of-pocket

In-network$4,700
Combined in + out$8,950
05

Skilled care at home

Home health

In-network$0 copay
Out-of-network50% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$87.40 / month
Consolidated C + D$128 / month

Source trail

Official CMS, Contract Year 2026

Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release. Quick-reference values should be confirmed in current official plan documents.

PBP benefits ↗ Landscape data ↗

Same CMS contract

H0107-003-000 Blue Cross Medicare Advantage Classic (PPO) MT Mid PPO · Local PPO H0107-005-000 Blue Cross Medicare Advantage Choice Plus (PPO) MT $0 Low PPO · Local PPO H0107-007-000 Blue Cross Medicare Advantage Dental Premier (PPO) MT Enhanced Dental PPO · Local PPO H0107-010-000 Blue Cross Medicare Advantage Health Choice (PPO) MT Flex Card PPO · Local PPO H0107-011-000 Blue Cross Medicare Advantage Protect (PPO) MT MA Only Buydown PPO · Local PPO H0107-801-000 Blue Cross Group Medicare Advantage Plan (PPO) Nationwide · Local PPO H0107-802-000 Blue Cross Group Medicare Advantage Plan (PPO) Nationwide · Local PPO H0107-803-000 Blue Cross Group Medicare Advantage Plan (PPO) Nationwide · Local PPO

About this code

What H0107-004-000 identifies

H0107-004-000 is a Contract Year 2026 Medicare plan segment code. The compact form H0107004000 refers to the same normalized contract, plan, and segment shown on this page.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.