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Medicare BlueSalute (PPO)

H3335 - 043 - 0
4 out of 5 stars (4 / 5)

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

This page features plan details for 2025 Medicare BlueSalute (PPO) H3335 – 043 – 0 available in Central New York.

Locations

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

Insurer:Excellus Health Plan, Inc
Health Plan Deductible:$0
MOOP:$7,800 In and Out-of-network
$4,500 In-network
Drugs Covered:No

Ready to sign up for Medicare BlueSalute (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

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

Medicare BlueSalute (PPO) qualifies for a monthly Medicare Give Back Benefit of $35.00.

Premium Reduction:$35.00

Premium Breakdown

Medicare BlueSalute (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.
Part B Part C Part B Give Back Total
$185.00 $0.00 $35.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Medicare BlueSalute (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

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $150 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $15 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $15 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Lab services
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $40 copay (Authorization Required)

Doctor visits

  • Specialist
    • In-Network: $35 copay per visit
  • Primary
    • In-Network: $5 copay per visit
    • Out-of-Network: 30% coinsurance per visit
  • Specialist
    • Out-of-Network: 30% coinsurance per visit

Emergency care/Urgent care

  • Emergency
    • $110 copay per visit (always covered)
  • Urgent care
    • $40 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • Out-of-Network: 30% coinsurance
  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $35 copay

Ground ambulance

    • In-Network: $200 copay
    • Out-of-Network: $200 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Medicare-Covered Hearing Exam
    • In-Network: $35 copay
    • Out-of-Network: 30% coinsurance
  • Hearing aids
    • In-Network: $499-799 copay (Limits Apply)
    • Out-of-Network: $499-799 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered

Inpatient hospital coverage

    • In-Network: $325 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • Out-of-Network: 30% per stay (Authorization Required)

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

    • $7,800 In and Out-of-network
      $4,500 In-network

Medical equipment/supplies

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

Medicare Part B drugs

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

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $324 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $0 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: 30% per stay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $0 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 30% coinsurance per visit (Authorization Required)
    • In-Network: $300 copay per visit (Authorization Required)

Preventive care

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

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
    • In-Network: $35 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $35 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)

Skilled Nursing Facility

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

Transportation

    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)

Vision

  • Eyeglass frames
    • Not covered
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Not covered
  • Upgrades
    • Not covered
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 30% coinsurance (Limits Apply)
    • In-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for Medicare BlueSalute (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

Table of Contents

Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

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