2022 Medicare BlueClassic (PPO)


Medicare BlueClassic (PPO) H3335-038 is a 2022 Medicare Advantage Plan or Part-C by Excellus Health Plan, Inc available to residents in New York. This plan includes additional prescription drug (Part-D) coverage. The Medicare BlueClassic (PPO) has a monthly premium of $38.00 and has an in-network maximum out-of-pocket limit of $7,200 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,200 out-of-pocket. This can be a extremely nice safety net.

Medicare BlueClassic (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Excellus Health Plan, Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Medicare BlueClassic (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Excellus Health Plan, Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Excellus Health Plan, Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Excellus Health Plan, Inc Medicare Advantage Plan Costs

Name:
Medicare BlueClassic (PPO)
Plan ID:
H3335-038
Provider:Excellus Health Plan, Inc
Year:2022
Type: Local PPO
Monthly Premium C+D: $38.00
Part C Premium:$0.00
MOOP: $7,200
Part D (Drug) Premium:$38.00
Part D Supplemental Premium$0.00
Total Part D Premium:$38.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:No
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H3335-043
New Plan: 2023 H3335-043




Medicare BlueClassic (PPO) Part-C Premium

Excellus Health Plan, Inc charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



H3335-038 Part-D Deductible and Premium

Medicare BlueClassic (PPO) has a monthly drug premium of $38.00 and a $0.00 drug deductible. This Excellus Health Plan, Inc plan offers a $38.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Excellus Health Plan, Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $38.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.



Excellus Health Plan, Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Excellus Health Plan, Inc plan does not offer additional coverage through the gap.



Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Medicare BlueClassic (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $9.50 for 75% low income subsidy $19.00 for 50% and $28.50 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$9.50
50% LIS Premium:$19.00
25% LIS Premium:$28.50


H3335-038 Formulary or Drug Coverage

Medicare BlueClassic (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Medicare BlueClassic (PPO) H3335-038 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $5
Tier 2 $8 $13
Tier 3 $42 $47
Tier 4 $95 $100
Tier 5 33% 33%
*Initial Coverage Phase and 30 day supply





2021 Medicare BlueClassic (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services Not covered
Endodontics Not covered
Extractions Not covered
Non-routine services Not covered
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered
Restorative services Not covered



Deductible


$0



Diagnostic Tests and Procedures


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



Doctor Visits


Primary $5 copay per visit
Primary $25 copay per visit (Out-of-Network)
Specialist $60 copay per visit (Out-of-Network)
Specialist $30 copay per visit



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $40 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $30 copay
Foot exams and treatment $60 copay (Out-of-Network)
Routine foot care Not covered



Ground Ambulance


$240 copay
$240 copay (Out-of-Network)



Hearing


Fitting/evaluation $0 copay
Fitting/evaluation $75 copay (Out-of-Network)
Hearing aids $699-999 copay
Hearing aids $699-999 copay (Out-of-Network)
Hearing exam $60 copay (Out-of-Network)
Hearing exam $30 copay



Inpatient Hospital Coverage


$360 per day for days 1 through 5
$0 per day for days 6 through 90
$435 per day for days 1 through 28
$0 per day for days 29 and beyond (Out-of-Network)



Medical Equipment/Supplies


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



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Chemotherapy 30% coinsurance (Out-of-Network)
Other Part B drugs 30% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $410 per day for days 1 through 28
$0 per day for days 29 through 90 (Out-of-Network)
Inpatient hospital - psychiatric $315 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit 20% coinsurance
Outpatient group therapy visit 30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 20% coinsurance
Outpatient individual therapy visit 30% coinsurance (Out-of-Network)
Outpatient individual therapy visit 20% coinsurance
Outpatient individual therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist 20% coinsurance



MOOP


$10,950 In and Out-of-network
$7,200 In-network



Option


No



Optional supplemental benefits


Yes



Outpatient Hospital Coverage


$350 copay per visit
30% coinsurance per visit (Out-of-Network)



Package #1


Deductible $100.00
Monthly Premium $29.00



Preventive Care


$0 copay
0-30% coinsurance (Out-of-Network)



Preventive Dental


Cleaning $0 copay
Cleaning $0 copay (Out-of-Network)
Dental x-ray(s) $0 copay (Out-of-Network)
Dental x-ray(s) $0 copay
Fluoride treatment Not covered
Oral exam $0 copay
Oral exam $0 copay (Out-of-Network)



Rehabilitation Services


Occupational therapy visit $50 copay (Out-of-Network)
Occupational therapy visit $40 copay
Physical therapy and speech and language therapy visit $40 copay
Physical therapy and speech and language therapy visit $50 copay (Out-of-Network)



Skilled Nursing Facility


30% per stay (Out-of-Network)
$0 per day for days 1 through 20
$184 per day for days 21 through 100



Transportation


Not covered



Vision


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



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Medicare BlueClassic (PPO) H3335



2021 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Medicare BlueClassic (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Medicare BlueClassic (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Medicare BlueClassic (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST




Coverage Area for Medicare BlueClassic (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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