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Medicare BlueEssential (PPO)

H3335 - 053 - 0
4 out of 5 stars (4 / 5)

Medicare BlueEssential (PPO) is a Medicare Advantage Plan by Excellus Health Plan, Inc.

This page features plan details for 2025 Medicare BlueEssential (PPO) H3335 – 053 – 0 available in Central New York.

Locations

Medicare BlueEssential (PPO) is offered in the following locations.

Broome County, New York
Cayuga County, New York
Chemung County, New York

Click to see more locations

Plan Overview

Medicare BlueEssential (PPO) offers the following coverage and cost-sharing.

Insurer:Excellus Health Plan, Inc
Health Plan Deductible:$0
MOOP:$11,300 In and Out-of-network
$8,850 In-network
Drugs Covered:Yes

Ready to sign up for Medicare BlueEssential (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Medicare BlueEssential (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Medicare BlueEssential (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $150.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $150.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Medicare BlueEssential (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay
    • Out-of-Network: No Coins – No Copay
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Lab services
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $45 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $60 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 30% coinsurance (Authorization Required)
    • In-Network: $175 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $25 copay per visit
  • Specialist
    • In-Network: $35 copay per visit
    • Out-of-Network: $60 copay per visit

Emergency care/Urgent care

  • Emergency
    • $110 copay per visit (always covered)
  • Urgent care
    • $45 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $35 copay
    • Out-of-Network: $60 copay
  • Routine foot care
    • Not covered

Ground ambulance

    • In-Network: $250 copay
    • Out-of-Network: $250 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • In-Network: $499-799 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Fitting/evaluation
    • Out-of-Network: $0 copay
  • Hearing aids
    • Out-of-Network: $499-799 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $35 copay
  • Fitting/evaluation
    • In-Network: $0 copay
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $60 copay

Inpatient hospital coverage

    • In-Network: $440 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • Out-of-Network: $435 per day for days 1 through 28
      $0 per day for days 29 and beyond (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $11,300 In and Out-of-network
      $8,850 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: $5 copay per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 30% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: 20% coinsurance (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: $410 per day for days 1 through 28
      $0 per day for days 29 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: 20% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: 20% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $405 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: 20% coinsurance (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $250 copay per visit (Authorization Required)
    • Out-of-Network: 30% coinsurance per visit (Authorization Required)

Preventive care

    • Out-of-Network: 0-30% coinsurance (Authorization Required)
    • In-Network: $0 copay (Authorization Required)

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $35 copay (Authorization Required)
    • Out-of-Network: $50 copay (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: $50 copay (Authorization Required)
    • In-Network: $35 copay (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 30% per stay (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Not covered
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $60 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Upgrades
    • Not covered
  • Eyeglass frames
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Medicare BlueEssential (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Medicare BlueEssential (PPO)? See 2025 Medicare BlueEssential (PPO) at MedicareAdvantageRX.com.

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