Medicare BlueSalute (PPO)
Medicare Plan Details (2023 Plan)
Monthly Premium

by Excellus Health Plan, Inc
Additional Coverage
Overall Government Star Rating
4.0Ready to Enroll Online?
Plan Type
Medicare Advantage (Part C)
Medicare Advantage combines Part A and Part B. This plan = Part A + Part B
Plan Details
$4,500 In-network
Medical Benefits
Doctor Services
Out-of-network: 30% coinsurance per visit
Out-of-network: 30% coinsurance per visit
Tests, labs, & imaging
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Hospital Services
$0 per day for days 6 through 90
Out-of-network: 30% per stay
Out-of-network: 30% coinsurance per visit
Skilled nursing facility
$196 per day for days 21 through 100
Out-of-network: 30% per stay
Preventive services
Out-of-network: 0-30% coinsurance
Ambulance
Out-of-network: $200 copay
Therapy services
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Mental health services
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Opioid treatment services
Other services
Out-of-network: 30% coinsurance per item
Out-of-network: 30% coinsurance 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
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Extra Benefits
Hearing
Out-of-network: 30% coinsurance
Out-of-network: $0 copay
Out-of-network: $499-799 copay
Preventive Dental
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Comprehensive dental
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Vision
Out-of-network: 30% coinsurance
Out-of-network: $0 copay
Out-of-network: $0 copay
Other benefits
Health Plan Star Ratings
(government star ratings are out of 5 stars)
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