Medicare BlueSalute (PPO) Plan Details for Schuyler County, NY
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*CMS rated this Excellus Health Plan, Inc plan (H3335-043-0) 4 (Good) out of 5 stars.
Medicare BlueSalute (PPO) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
See more Medicare Advantage Plans in Schuyler County, New York.
Medicare BlueSalute Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H3335-043-0 |
| Plan Type: | PPO |
| Plan Year: | 2025 |
| Premium: | $0.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 4,500.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Not Included |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Schuyler County, NY |
| Insured By: | Excellus Health Plan, Inc |
| Summary of Benefits |
|---|
Excellus Health Plan, Inc Out-of-Pocket Costs
This Excellus Health Plan, Inc Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H3335-043-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
| Healthcare Service | Member Cost |
|---|---|
| Doctor Visits (In-Network) | |
| Primary: | $5 Copay |
| Specialist: | $35 Copay |
| Preventive care: | $0 |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | $35 Copay |
| Routine foot care: | Not Covered |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | $5 Copay |
| Routine chiropractic care: | Not Covered |
| Emergency Care / Urgent Care | |
| Emergency room care: | $110 Copay |
| Urgent care: | $40 Copay |
| Ground ambulance: | $200 Copay |
| Inpatient hospital coverage: | $325.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Outpatient hospital coverage: | $300 Copay Prior Authorization Required |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
| Optional supplemental benefits: | |
| Mental Health Services (In-Network) | |
| Outpatient individual therapy visit with a psychiatrist: | $0 |
| Outpatient group therapy visit with a psychiatrist: | $0 |
| Inpatient hospital - psychiatric: | $324.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Outpatient group therapy visit: | $0 |
| Outpatient individual therapy visit: | $0 |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | $35 Copay Prior Authorization Required |
| Occupational therapy visit: | $35 Copay Prior Authorization Required |
| Medical Equipment / Supplies (In-Network) | |
| Diabetes supplies: | $5 Copay Prior Authorization Required |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
| Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
| Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
| Diagnostic radiology services (e.g., MRI): | $150 Copay Prior Authorization Required |
| Lab services: | $15 Copay Prior Authorization Required |
| Outpatient x-rays: | $40 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $15 Copay Prior Authorization Required |
| Medicare Part B Drugs (In-Network) | |
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Medicare BlueSalute Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Excellus Health Plan, Inc includes with this plan:
| Supplemental Healthcare Service | Member Cost |
|---|---|
| Preventive Dental | |
| Oral exam (In-Network) | Not Covered |
| Fluoride treatment (In-Network) | Not Covered |
| Dental x-ray(s) (In-Network) | Not Covered |
| Cleaning (In-Network) | Not Covered |
| Comprehensive Dental | |
| Periodontics (In-Network) | Not Covered |
| Non-routine services (In-Network) | Not Covered |
| Diagnostic services (In-Network) | Not Covered |
| Extractions (In-Network) | Not Covered |
| Endodontics (In-Network) | Not Covered |
| Restorative services (In-Network) | Not Covered |
| Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
| Hearing Aids | |
| Fitting/evaluation (In-Network) | Covered Limits may apply |
| Hearing aids (In-Network) | Not Covered |
| Hearing exam (In-Network) | Covered Limits may apply |
| Vision | Maximum vision benefit: | $2.00 Every three years |
| Eyeglasses (frames and lenses) (In-Network) | Not Covered |
| Routine eye exam (In-Network) | Covered Limits may apply |
| Contact lenses (In-Network) | Not Covered |
Prescription Drug Plan Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) and drug plans (Part D) in several major categories using a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join Medicare BlueSalute .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall 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 |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- Medicare BlueEnhanced
- Medicare Blue Choice Discovery
- Medicare BlueSalute
- Univera SeniorChoice Core
- Medicare BlueFlex
- Medicare BluePlus
- Medicare BlueEssential
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Excellus Health Plan, Inc
| Plan Website: | http://www.ExcellusMedicare.com |
|---|---|
| Formulary Information: | http://www.ExcellusMedicare.com |
| Pharmacy Information: | Excellus Health Plan, Inc Pharmacy Page |
| Prospective Members: | (800)659-1986 |
| TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Excellus Health Plan, Inc, http://www.ExcellusMedicare.com, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You in Different Formats", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.