Medicare BlueClassic (PPO)

For Coverage January 1, 2019 to December 31, 2019

Plan Features

  • Dedicated Customer Care department
  • No referrals required
  • $0 copay for all Tier 1 Preferred Generic drugs
  • For a 90-day supply, you pay 2 times the copayment for a 30-day supply of your prescription
  • $120 annual eyewear allowance
  • Worldwide urgent care and emergency coverage
  • Coverage for preventive dental care including 2 oral exams, 2 cleanings, and 2 x-rays per year1
  • Silver&Fit® Fitness Program (learn more)
    • $25 annual non-refundable fee to enroll in a participating fitness club or exercise center;
    • $10 annual non-refundable fee to enroll in the home fitness program; or
    • $150 annual allowance for out-of-network facilities.

Benefits2

Medical Coverage
Medicare BlueClassic (PPO) provides comprehensive coverage for the health care services you need, including:

  • $5 copay per visit for in-network primary care providers
  • $30 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
  • $4 copay for in-network chiropractic medical visits
  • Inpatient Hospital Stay
    • $360 copay per day for days 1-5 for each Medicare-covered stay at a network hospital
    • Days 6+ covered in full

Prescription Drug Coverage3
Our prescription drug coverage features:

Tier 30-Day Supply 90-Day Supply
Tier 1 Preferred Generic Drugs $0 $0
Tier 2 Generic Drugs $8 $16
Tier 3 Preferred Brand Drugs $47 $94
Tier 4 Non-Preferred Brand Drugs $100 $200
Tier 5 Specialty Drugs 33% 33%

 

  • $0 annual deductible (this is the amount you must pay for prescriptions before we begin to pay)
  • 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

Learn more with these resources:

1 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.

2 This information is not a complete description of benefits. Call 1-800-671-6081 (TDD/TTY 1-800-421-1220) for more information.

3 Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances. Quantity limitations and restrictions may apply.

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 (TTY/TDD 1-800-421-1220). 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.

 

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. .
This page last updated .