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Medicare BlueEssential (PPO)
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MDC-Medicare BlueEssential - Plan Features - Even
- NEW for 2020, add Full Comprehensive Dental coverage to your plan, for an additional $39 a month. This includes coverage for restorative and major dental services (i.e., crowns, root canals). Coverage for preventive dental services (i.e., cleanings and x-rays) is included with your plan.3 (View our Supplemental Dental plans)
- NEW for 2020, you pay 50% of the cost for up to 10 acupuncture visits.
- Dedicated Customer Care department
- No referrals required
- $120 annual eyewear allowance
- Worldwide urgent care and emergency coverage
- The Silver&Fit® Fitness Program. $25 annual non-refundable fee for gym membership. Other program options are available. Find a participating fitness center near you.
- Coverage for hearing aids through our partner TruHearing® (a copayment will apply)
MDC-Medicare BlueEssential - Benefits - Even
Medicare BlueEssential (PPO) provides comprehensive coverage for the health care services you need, including:
- $10 copay per visit for in-network primary care providers
- $40 copay per visit for in-network specialists
- $0 copay for many Medicare-covered preventive services, such as in-network physical exams, smoking cessation and some immunizations
- $10 copay for in-network chiropractic medical visits
- Inpatient Hospital Stay
- $380 copay per day for days 1-5 for each Medicare-covered stay at a network hospital
- Days 6+ covered in full
Prescription Drug Coverage2
In 2020, you may save on prescription drugs and vaccines when they are filled at our preferred pharmacies. You may pay more at standard pharmacies.
Your prescription drug costs. You pay 2 times the copayment for a 30-day supply of your prescription at the pharmacy or through mail order:
|Tier||Preferred Pharmacy |
|Preferred Pharmacy |
|Standard Pharmacy |
|Standard Pharmacy |
|Tier 1 Preferred Generic Drugs (Includes select vaccines like the shingles vaccine shingrix®)||$0||$0||$5||$10|
|Tier 2 Generic Drugs||$10||$20||$15||$30|
|Tier 3 Preferred Brand Drugs||$42||$84||$47||$94|
|Tier 4 Non-Preferred Drugs||$95||$190||$100||$200|
|Tier 5 Specialty Drugs||31%||31%||31%||31%|
- $100 annual deductible on Tiers 3, 4 and 5 Drugs (you must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan’s deductible amount). For all other drugs, you will not have to pay any deductible and will start receiving coverage immediately.
- Additional savings when you take advantage of our mail order and select retail pharmacies that provide lower cost-sharing for a 90-day supply of your prescription drug(s)
- The 5-Tier comprehensive formulary includes Tier 1, 2, 3, 4 and 5 drugs. Follow this link to Search for a Medication and View Drug Tier and Copayment or Coinsurance Information
- 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
MDC-Medicare BlueEssential - Learn More - Even
Learn more with these resources:
2 Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances. Quantity limitations and restrictions may apply.
3 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.
Network Coverage Information - With our Medicare Advantage Preferred Provider Organization (PPO) plans you have access to both In- and Out-of-Network providers and you may see any Medicare participating provider. However, your out-of-pocket costs may be higher when you use an Out-of-Network provider, except in limited cases such as emergencies and urgently needed care. For information on how to request reimbursement for Out-of-Network claims, and information on Out-of-Network Coverage 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 (TDD/TTY 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.
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.
To the extent of any discrepancy between this website and the Evidence of Coverage, the Evidence of Coverage terms take priority.
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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
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Excellus BlueCross BlueShield contracts with the Federal Government and 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_5993.
This page last updated 10-01-2019.