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  1. NY
  2. Excellus Health Plan, Inc
  3. Plan

Medicare BlueSalute (PPO)

Medicare Plan Details (2023 Plan)

Monthly Premium

 

by Excellus Health Plan, Inc
Additional Coverage
HearingVisionDental
Overall Government Star Rating
 4.0
out of 5 stars

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Plan Type

Medicare Advantage (Part C)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B

 

Plan Details

$0
$0
$0
$0
$7,800 In and Out-of-network
$4,500 In-network
No
Yes
Yes
Yes
http://www.ExcellusMedicare.com
http://www.ExcellusMedicare.com

Medical Benefits

Doctor Services

In-network: $5 copay per visit
Out-of-network: 30% coinsurance per visit
In-network: $35 copay per visit
Out-of-network: 30% coinsurance per visit

Tests, labs, & imaging

In-network: $15 copay
Out-of-network: 30% coinsurance
In-network: $15 copay
Out-of-network: 30% coinsurance
In-network: $150 copay
Out-of-network: 30% coinsurance
In-network: $40 copay
Out-of-network: 30% coinsurance
$95 copay per visit (always covered)
$40 copay per visit (always covered)

Hospital Services

In-network: $325 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: 30% per stay
In-network: $300 copay per visit
Out-of-network: 30% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$196 per day for days 21 through 100
Out-of-network: 30% per stay

Preventive services

In-network: $0 copay
Out-of-network: 0-30% coinsurance

Ambulance

In-network: $200 copay
Out-of-network: $200 copay

Therapy services

In-network: $35 copay
Out-of-network: 30% coinsurance
In-network: $35 copay
Out-of-network: 30% coinsurance

Mental health services

In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: 30% coinsurance

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: $5 copay per item
Out-of-network: 30% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 30% coinsurance
In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Extra Benefits

Hearing

In-network: $35 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: $499-799 copay
Out-of-network: $499-799 copay

Preventive Dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Not covered
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Not covered
Not covered
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Vision

In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Limited coverage
Limited coverage

Health Plan Star Ratings

(government star ratings are out of 5 stars)
 3.5
 4
 3
 3
 4
 4

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