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Medicare BlueEssential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare BlueEssential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare BlueEssential (PPO) in 2025, please refer to our full plan details page.
Medicare BlueEssential (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 BlueEssential (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 BlueEssential (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 BlueEssential (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 a $150.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $11300.00 (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 $11300.00 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:
Sign up for Medicare BlueEssential (PPO)
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Drug Coverage
The Medicare BlueEssential (PPO) plan has a $150 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For generic drugs, you can expect to pay a $10-$15 copay, while preferred brand drugs have a 50% coinsurance. Non-preferred drugs have a 31% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Medicare BlueEssential (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, with no copay for days 6-90, while outpatient services have a $250 copay. Emergency services range from a $45 to $250 copay, and primary care visits have a $15-$35 copay, while many other services like hearing and vision exams, and dental services, have copays. The plan also includes coverage for preventive services, home health services with no copay, and skilled nursing facilities with a copay after 20 days. Diagnostic and radiological services, medical equipment, and home infusion services have coinsurance requirements. Certain services like cardiac rehabilitation, and some other services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $440 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will pay a $405 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center (ASC) Services, have a $250 copay. Outpatient Substance Abuse Services, including individual and group sessions, have a 20% coinsurance. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Medicare BlueEssential (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 by the Medicare BlueEssential (PPO) plan, with a $250 copay for both ground and air ambulance services and no coinsurance. 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 under the Medicare BlueEssential (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $250 copay.
Primary Care See details
The Medicare BlueEssential (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, and mental health specialty services and psychiatric services with 20% coinsurance. The plan also covers physical therapy and speech-language pathology services with a $35 copay. The plan's additional telehealth benefits have a 20% coinsurance and a copay between $0 and $35.
Preventive Services See details
Preventive Services are covered by the Medicare BlueEssential (PPO) plan, including Medicare-covered preventive services, annual physical exams, health education, fitness benefits, enhanced disease management, remote access technologies, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit; however, 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. Prior authorization is required for Medicare-covered preventive services.
Hearing Services See details
Hearing Services for the Medicare BlueEssential (PPO) plan include hearing exams with a $35 copay, and Routine Hearing Exams are covered annually. Prescription Hearing Aids are covered, with a copay between $499 and $799. However, Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC Hearing Aids are not covered.
Vision Services See details
The Medicare BlueEssential (PPO) plan covers vision services, including routine eye exams once per year with no deductible, and eyewear. Eyewear, including contact lenses, has a $35 copay, and has a combined maximum plan benefit coverage amount of $100 every year for both in-network and out-of-network services. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Medicare BlueEssential (PPO) plan covers dental services, including oral exams, dental x-rays, prophylaxis (cleaning), restorative services, adjunctive general services, endodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Oral exams, dental x-rays, and cleaning have a $35 copay, with 2 visits per year. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic Services have a $1,000 maximum benefit per year. Periodontics has 2 visits per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 under the Medicare BlueEssential (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered under the Medicare BlueEssential (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, while Diabetic Supplies have a $5 copay and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Medicare BlueEssential (PPO) plan, although Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $175.00, while Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have a copay of $45.00.
Home Health Services See details
Home Health Services are covered by the Medicare BlueEssential (PPO) plan, with no copay or coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Medicare BlueEssential (PPO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Medicare BlueEssential (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Under the Medicare BlueEssential (PPO) plan, acupuncture is covered with 50% coinsurance, but is limited to 10 treatments per year. Over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, 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, and Self-Directed Personal Assistance Services are not covered.
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