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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 2026, 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 Greater Syracuse Region. This plan received an overall rating of 3.5 out of 5 stars in 2026.
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 $615.00 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 features an annual drug deductible of $615 before initial coverage begins. For Tier 1 preferred generic drugs, you will pay a low copay starting at $5 for a one-month supply at preferred pharmacies or mail-order services, compared to $10 at standard pharmacies. Tier 2 generic drugs are also highly affordable, with a $15 copay at preferred pharmacies and a $20 copay at standard pharmacies for a one-month supply. Brand-name and specialty medications under this plan are subject to coinsurance rather than flat copays during the initial coverage phase. Tier 3 preferred brand drugs require a 20% coinsurance at preferred locations and 25% at standard pharmacies, while Tier 4 non-preferred drugs range from 25% to 50% coinsurance depending on your pharmacy choice. Specialty drugs in Tier 5 require a flat 25% coinsurance across both preferred and standard pharmacies and mail-order options.
Additional Benefits
Medicare BlueEssential (PPO) offers comprehensive medical coverage with predictable costs, featuring a $5 copay for primary care visits and a $40 copay for specialist visits with no coinsurance. Emergency care is available with a $115 copay, while inpatient hospital stays require a $440 copay for the first five days of acute stays and no copay for subsequent days. Outpatient hospital services and ambulatory surgical center visits carry a $350 copay with no coinsurance, ensuring manageable upfront costs for major procedures. Routine preventive care, annual vision exams, and preventive dental services like cleanings are fully covered with no copay and no coinsurance. For specialized care, the plan provides comprehensive dental coverage up to a $500 annual limit, prescription hearing aids with copays between $499 and $799, and home health services with no copay. Durable medical equipment, prosthetics, and dialysis services are also covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Medicare BlueEssential (PPO) covers inpatient hospital services with no coinsurance, requiring a $440 copay for days 1-5 of acute stays and a $405 copay for days 1-5 of psychiatric stays, followed by no copay for subsequent days. Prior authorization is required, and non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Medicare BlueEssential (PPO) covers outpatient hospital, observation, and ambulatory surgical center services with a $350 copay and no coinsurance. Outpatient substance abuse services are covered with no copay and a 20% coinsurance, while outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under Medicare BlueEssential (PPO) with no copay and a 20% coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Medicare BlueEssential (PPO) covers ground and air ambulance services with a $300 copay and no coinsurance, though prior authorization is required. For transportation services, some services are covered, but trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
Medicare BlueEssential (PPO) covers emergency services with a $115 copay (waived if admitted within 23 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $115, $40, and $300 respectively.
Primary Care See details
Medicare BlueEssential (PPO) offers primary care visits for a $5 copay and specialist visits for a $40 copay, both with no coinsurance, while physical and occupational therapy require a $35 copay with no coinsurance. Mental health and psychiatric services feature no copay and a 20% coinsurance, whereas podiatry is not covered, and routine or other chiropractic services are also not covered.
Preventive Services See details
Preventive services are covered by Medicare BlueEssential (PPO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive services are partially covered, excluding health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Medicare BlueEssential (PPO) offers partially covered hearing services, including routine annual hearing exams for a $40 copay and no coinsurance, and unlimited fitting evaluations. Prescription hearing aids are covered with a copay between $499 and $799 and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by Medicare BlueEssential (PPO), offering one routine eye exam per year with no copay, no coinsurance, and no deductible. Eyewear is covered with no coinsurance, no deductible, and a $40 copay for contact lenses up to a $100 annual limit, though other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services under Medicare BlueEssential (PPO) are partially covered, with Medicare-covered dental services requiring a $40 copay and no coinsurance, and other covered services like exams, cleanings, and x-rays having no copay and no coinsurance. A $500 annual limit applies to comprehensive services, while fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Medicare BlueEssential (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs carry no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Medicare BlueEssential (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Medicare BlueEssential (PPO) covers medical equipment, featuring no copay and a 20% coinsurance for durable medical equipment (DME) and prosthetics. Covered diabetic supplies require a $5 copay, while diabetic therapeutic shoes or inserts have a 20% coinsurance, with prior authorization required.
Diagnostic and Radiological Services See details
Medicare BlueEssential (PPO) diagnostic and radiological services are partially covered and require prior authorization, with diagnostic procedures, tests, and lab services not covered. Covered diagnostic services have no copay and no coinsurance, while radiological services require a $55.00 copay for outpatient X-rays, a minimum $245.00 copay for diagnostic radiological services, and a 20% minimum coinsurance for therapeutic radiological services.
Home Health Services See details
Medicare BlueEssential (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Medicare BlueEssential (PPO) with no coinsurance, but some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered. Covered services under this benefit require a $15 copay.
Skilled Nursing Facility (SNF) See details
Medicare BlueEssential (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and does not require a prior three-day hospital stay, though prior authorization is required. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with additional days beyond the standard 100 days not covered.
Other Services See details
Medicare BlueEssential (PPO) partially covers other services, offering up to 10 acupuncture treatments per year with no copay and a 50% coinsurance. Supplemental benefits such as over-the-counter (OTC) items and meal benefits are not covered.
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