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Medicare BlueClassic (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare BlueClassic (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare BlueClassic (PPO) in 2025, please refer to our full plan details page.
Medicare BlueClassic (PPO) is a PPO plan offered by Lifetime Healthcare, Inc. available for enrollment in 2025 to people living in Central New York. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Medicare BlueClassic (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Medicare BlueClassic (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Medicare BlueClassic (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $31.50. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Medicare BlueClassic (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have an $8 copay at preferred pharmacies, while preferred brand drugs have a 50% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Medicare BlueClassic (PPO) plan offers a wide array of benefits, including inpatient hospital stays with a copay, outpatient services with a $275 copay, and emergency services with varying copays. Primary care, hearing, vision, and dental services are also covered, each with specific copays or coinsurance. This plan also includes coverage for home health services with no copay, and Skilled Nursing Facility (SNF) services with a copay after the initial 20 days. Additional benefits include ambulance services, prescription hearing aids, and home infusion services. The plan also provides coverage for medical equipment, diagnostic and radiological services, and dialysis services. However, some services like cardiac rehabilitation, and certain dental and vision procedures are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization. For Inpatient Hospital-Acute, there is a $360 copay for days 1-5, and no copay for days 6-90, while for Inpatient Hospital Psychiatric, there is a $315 copay for days 1-5, and no copay for days 6-90. Additional days and non-Medicare-covered stays for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and ambulatory surgical center services, are covered with a copay of $275.00. Outpatient substance abuse services are covered with a 20% coinsurance for both individual and group sessions, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Medicare BlueClassic (PPO) plan, but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under Medicare BlueClassic (PPO), with a $240 copay for both ground and air ambulance services; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Medicare BlueClassic (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $40 copay, and Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $240 copay.
Primary Care See details
The Medicare BlueClassic (PPO) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy with a $30 copay, physician specialist services with a $30 copay, and physical therapy and speech-language pathology services with a $30 copay. Mental health and psychiatric services have a 20% coinsurance for individual and group sessions, and other health care professionals have a 50% coinsurance and a $30 copay. Additional telehealth benefits include a 20% coinsurance and a copay between $0 and $30. Opioid treatment program services have a 20% coinsurance. Routine chiropractic care is not covered, nor are podiatry services.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with prior authorization, annual physical exams, health education, fitness benefits (memory fitness), enhanced disease management, remote access technologies, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. In-home safety assessments, personal emergency response systems, medical nutrition therapy, post discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $30 copay for one visit per year and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $499 and $799 for two hearing aids per year, but Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services include routine eye exams and eyewear coverage. Routine eye exams are covered once per year, and there is no copay. Eyewear, including contact lenses, is covered with a $30 copay, and has a combined maximum plan benefit coverage amount of $100 every year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered under the Medicare BlueClassic (PPO) plan, with a $30 copay for Medicare dental services. Oral exams, dental x-rays, and cleaning are covered, but fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $1000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Medicare BlueClassic (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with no copay and a 20% coinsurance. Diabetic Equipment is covered with a copay of $5 and a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Medicare BlueClassic (PPO), but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $175, Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $45 copay.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Medicare BlueClassic (PPO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. There is no copay for days 1-20, and a $214 copay per day for days 21-100; additional days beyond Medicare-covered are not covered.
Other Services See details
Other Services under the Medicare BlueClassic (PPO) plan covers acupuncture with a 50% coinsurance and a limit of 10 treatments per year, but it does not cover over-the-counter items, meal benefits, dual eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services.
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