Medicare BlueClassic (PPO) Plan Details for Tompkins County, NY
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*CMS rated this Excellus Health Plan, Inc plan (H3335-038-0) 4 (Good) out of 5 stars.
Medicare BlueClassic (PPO) is a Medicare Advantage plan with Part D benefits. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
See more Medicare Advantage Plans in Tompkins County, New York.
Medicare BlueClassic Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H3335-038-0 |
| Plan Type: | PPO |
| Plan Year: | 2025 |
| Premium: | $31.50/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 7,200.00 /yr (in-network) |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Tompkins 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 H3335-038-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $30 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $110 Copay |
| Urgent care: | $40 Copay |
| Ground ambulance: | $240 Copay |
| Inpatient hospital care: | $360.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $30 Copay |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $10 Copay |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | 20% Coinsurance |
| Outpatient group therapy: | 20% Coinsurance |
| Inpatient psychiatric hospital care: | $315.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $30 Copay Prior Authorization Required |
| Occupational therapy: | $30 Copay Prior Authorization Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | $5 Copay Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $175 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | $45 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | Not Covered |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $30 Copay |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam | |
| Routine eye exam | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our Medicare BlueClassic Summary of Benefits information.
Prescription Drug Costs & Benefits
Medicare BlueClassic includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Part D Prescription Drug Premium
The table below outlines the Part D premium costs for this Excellus Health Plan, Inc plan, showing the monthly portion of the total premium dedicated to prescription drug coverage. While the Part D premium is included in the overall plan cost, some plans may have supplemental charges or offer assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security initiative that helps individuals with limited income and resources reduce or eliminate Part D expenses.
| Basic Part D Premium: | $31.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $31.00 |
| Low Income Premium Subsidy: | $72.34 |
| Low Income Premium Subsidy CMS Pays: | $31.00 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. You must pay this amount at the pharmacy before Excellus Health Plan, Inc begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Medicare BlueClassic has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Preferred Generic | $0.00 | $5.00 | |
| Generic | $8.00 | $13.00 | |
| Preferred Brand | $42.00 | $47.00 | |
| Non-Preferred Drug | 50.00% | 50.00% | |
| Specialty Tier | 33.00% | 33.00% | |
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
The following table shows the quality ratings for this Excellus Health Plan, Inc plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent ratings for Medicare BlueClassic .
| 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 BlueFlex (PPO)
- Medicare BlueSalute (PPO)
- Medicare BlueEssential (PPO)
- Univera SeniorChoice Core (PPO)
- Medicare BlueSalute (PPO)
- Medicare BlueClassic (PPO)
- Medicare Blue Choice Discovery (PPO)
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
| Website: | Excellus Health Plan, Inc Plan Page |
|---|---|
| Providers: | Excellus Health Plan, Inc Providers Page |
| Formulary: | Excellus Health Plan, Inc Formulary Page |
| Pharmacy: | Excellus Health Plan, Inc Pharmacy Page |
| New Member Health Plan Help: | (800)659-1986 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (800)659-1986 |
| New Member Part D 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.