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Medicare BlueActive (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare BlueActive (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare BlueActive (PPO) in 2025, please refer to our full plan details page.
Medicare BlueActive (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 BlueActive (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 BlueActive (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 BlueActive (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. Additionally, this plan comes with a Part B Premium reduction of $48.00. You must continue to pay paying your reduced 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 $350.00 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:
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Drug Coverage
The Medicare BlueActive (PPO) plan has an enhanced alternative drug benefit. The plan has a $350 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, you'll pay a $12 copay for preferred generic drugs at a preferred pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Medicare BlueActive (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, with costs differing based on the type of care and length of stay, while outpatient services come with a copay or coinsurance depending on the type of service. Emergency services and primary care visits have set copays, and preventive services are covered with no copay. Additional benefits include coverage for hearing, vision, and dental services, each with its own copays and limits. The plan also covers services like ambulance, home health, and skilled nursing facilities, with varying cost-sharing structures. The plan also offers coverage for medical equipment, along with diagnostic and radiological services, and other services such as acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, there is a $400 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, there is a $374 copay for days 1-5, and no copay for days 6-90. Additional days and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered. Non-Medicare-covered stays are not covered for either benefit.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services, observation services, and ambulatory surgical center services each have a $350 copay, while individual and group outpatient substance abuse sessions have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered, 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 the Medicare BlueActive (PPO) plan. Ground and Air Ambulance Services have a $300 copay, and there is 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. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services and Worldwide Urgent Coverage have a $45 copay, and Worldwide Emergency Transportation has a $300 copay; all services have no coinsurance.
Primary Care See details
The Medicare BlueActive (PPO) plan covers primary care physician services with a $5 copay, chiropractic services with a $15 copay, and occupational therapy with a $35 copay. It also covers physician specialist services with a $40 copay, individual and group mental health and psychiatric sessions with 20% coinsurance, and physical therapy and speech-language pathology services with a $35 copay. Additional telehealth benefits are covered with 20% coinsurance and a copay ranging from $0 to $40, and Opioid Treatment Program Services are covered with 20% coinsurance. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services, including Medicare-covered services, annual physical exams, and additional preventive services, are covered with no copay. Some services under Additional Preventive Services, such as In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), and others, are not covered.
Hearing Services See details
Hearing Services are covered, including routine hearing exams with a $40 copay, and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $499 and $799, but 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
Vision services include coverage for routine eye exams, contact lenses, and eyeglasses (lenses and frames). Eyewear, including contact lenses, has a $40 copay, and there is a combined maximum benefit of $200 every year for all eyewear.
Dental Services See details
The Medicare BlueActive (PPO) plan offers dental services, including a $40 copay for Medicare dental services. Oral exams, dental x-rays, and prophylaxis (cleaning) are covered, with a limit of 2 visits per year for each service. Orthodontic services have a maximum benefit of $1,000 per year, and restorative services, adjunctive general services, endodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with no limits. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
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. 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 BlueActive (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and 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, including all diagnostic services, diagnostic procedures/tests, and lab services, are covered by the Medicare BlueActive (PPO) plan. Diagnostic Procedures/Tests and Lab Services have a $15 copay, while Diagnostic Radiological Services have a $300 copay, and Outpatient X-Ray Services have a $60 copay. Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Medicare BlueActive (PPO) plan 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 covered, but the specific services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a copay for Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services and Additional Cardiac Rehabilitation Services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Medicare BlueActive (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Medicare BlueActive (PPO) plan covers acupuncture with a 50% coinsurance, but it is limited to 10 treatments per year. Over-the-counter (OTC) items are covered with a maximum benefit of $50 every three months and includes nicotine replacement therapy. However, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and several other services are not covered.
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