Medicare BlueActive (PPO)
For Coverage January 1, 2022 to December 31, 2022
|Primary Care Doctor/Specialist Copay Per Visit||Prescription Drugs||Preventive Dental||Eyewear|
|$15/$45 (In Network)||Covered||Covered||
$250 every 2 years
|Primary Care Doctor/Specialist Copay Per Visit||Prescription Drugs|
|$15/$45 (In Network)||Covered|
$250 every 2 years
Get $40/month back in your Social Security check with a Part B refund.
$0 Routine Eye Exam and $250 Eyewear Allowance every two years
Annual Routine Hearing Exam $45 copay, Hearing Aids $699 & $999 per unit
Part D Prescriptions: $350 deductible on Tiers 3, 4, and 5 Drugs, $3 for Tier 1 preferred generic drugs and vaccines at preferred pharmacies. Save up to 33% on prescriptions when you use mail-order pharmacy.
$30 allowance every three months for items such as allergy medication, antacids, digestive aids, cold & flu medication, denture products, and more.
Get care from the people and places you know and trust using our robust network of doctors, hospitals, and pharmacies. Along with urgent and emergency care when you travel.
Telehealth for care by telephone, email or chat
Get mental health support via in-person and telehealth visits, with a participating licensed therapist (20% coinsurance) and/or psychiatrist (specialist copay applies).
Our local teams of doctors, nurses, dietitians and specialists are here to support your wellbeing, including healthy eating, managing prescriptions, health conditions, and more. Plus, members have access to our 24/7 Nurse Call Line.
With the Silver&Fit Fitness Benefits Program you can join a participating fitness center for a $25 annual fee, workout from home with a home fit kit (1 kit / $10 annual fee), and access online digital workouts.
Medicare BlueActive (PPO) provides comprehensive coverage for the health care services you need, including:
|Part B Refund||
$40/month Part B refund in your Social Security check
|Primary Care Doctors Visit (In-network)||
$15 copay per visit
|Specialists Visit (In-network)||
$45 copay per visit
$15 copay per service
$250 every 2 years
|Inpatient Hospital Stay (In-network)||
$400 copay per day for days 1-5, days 6+ covered in full
|Oupatient Hospital Coverage (In-network)||
|Maximum Out-of-Pocket (In-network)||
$7,550 per year
Prescription Drug Coverage
You are covered locally and nationally with our extensive network of 65,000 pharmacies. Choose from retail, home delivery, long-term care, specialty, home infusion, or Indian/Tribal/Urban pharmacies. Save money with lower copays on your Tiers 1-4 medications when you use one of our 35,000 preferred pharmacies. Higher copays apply for medications on Tiers 1-4 if a standard pharmacy is utilized. Prescriptions filled at non-network pharmacies are covered only in certain situations.
|Preferred Pharmacy||Preferred Pharmacy||Standard Pharmacy||Standard Pharmacy|
|Tier||30-Day Supply||90-Day Supply||30-Day Supply||90-Day Supply|
|Tier 1 Preferred Generic Drugs (Includes select vaccines)||
|Tier 2 Generic Drugs||
|Tier 3 Preferred Brand Drugs||
|Tier 4 Non-Preferred Drugs||
|Tier 5 Specialty Drugs||
A prescription drug deductible may apply, check the Evidence of Coverage (EOC) for additional details.
Our 5 Tier comprehensive formulary and searchable medication database will help you determine if your prescription drug is covered by the Plan or if any utilization edits apply, such as prior authorization or step therapy.
For additional savings, ask your doctor for a 90-day supply of your medication and fill the prescription at a local pharmacy or through home delivery. For most plans, you pay 1 copayment for a 30-day supply and 2 copayments for a 90-day supply.
Our nationwide network includes thousands of participating pharmacies. Additionally, Excellus BlueCross BlueShield has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area.
Want to Meet?
Find your local Medicare Sales Advisor.
Visit our Resource Center at
1946 West Ridge Road
Rochester, NY 14626 Hours
Monday - Friday:
8 a.m. to 8 p.m.
From Oct. 1 - Dec. 30:
Advisors are also available weekends 8 a.m. to 8 p.m.
Closed Thanksgiving Day, Christmas Eve, Christmas Day, New Year’s Eve, and New Year’s Day
Need information in a different format?
Learn more with these resources:
- Summary of Benefits with Multi-Language FlyerOpen a PDF
- Evidence of CoverageOpen a PDF
- Plan Ratings
- Disenrollment Rights & Responsibilities
- Low-Income Subsidy (LIS) Premium Summary Chart
Network Coverage Information - With our Medicare Advantage Health Maintenance Organization (HMO) plans you must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from Out-of-Network providers neither Medicare nor Excellus BlueCross BlueShield will be responsible for the costs. For information on how to request reimbursement for Out-of-Network claims from emergency, urgent or other services, or Coverage Determinations and Appeals call Customer Care at 1-877-883-9577, Monday - Friday, 8 a.m. to 8 p.m.; From October 1 through March 31, 8 a.m. to 8 p.m., 7 days a week (TTY/TDD 1-800-662-1220). Or, see the Evidence of Coverage using the link above. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
For out-of-network providers, we will pay 100% of the allowance or dentist charges, whichever is less. You will be responsible for the balance.
Out-of-network/non-contracted providers are under no obligation to treat Excellus BlueCross BlueShield members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
To the extent of any discrepancy between this web site and the Evidence of Coverage, the Evidence of Coverage terms take priority.
Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_8095_M.
This page last updated 10-01-2021.