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Medicare BlueVital (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare BlueVital (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare BlueVital (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Medicare BlueVital (PPO) is a PPO plan offered by Excellus Health Plan, Inc. available for the 2026 plan year to people living in Cental New York. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Medicare BlueVital (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 BlueVital (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 BlueVital (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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9250.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $9250.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $11700.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $11700.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 BlueVital (PPO) plan features an annual drug deductible of $615 before coverage begins. For Tier 1 preferred generic drugs, you will pay a low copayment starting at $5.00 for a one-month supply at preferred pharmacies and mail-order services, or $10.00 at standard pharmacies. Tier 2 generic drugs are also budget-friendly, with copayments starting at $15.00 for a one-month supply at preferred locations and $20.00 at standard pharmacies. For higher-tier medications, costs are determined by coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 20% coinsurance at preferred pharmacies and 25% at standard pharmacies, while Tier 4 non-preferred drugs range from 25% to 50% coinsurance. Tier 5 specialty drugs require a flat 25% coinsurance across all pharmacy and mail-order options, making preferred network pharmacies the most cost-effective choice for most prescriptions.
Additional Benefits
Medicare BlueVital (PPO) offers comprehensive coverage for essential medical needs, starting with a $10 copay for primary care visits and a $55 copay for specialists. For hospital care, inpatient stays carry a $475 daily copay for days 1 through 5 and no copay for days 6 through 90, while emergency room visits require a $115 copay. Outpatient hospital services are covered with a $450 copay and no coinsurance, and diagnostic lab services require a $15 copay. Beneficiaries pay no copay and no coinsurance for preventive services, home health care, and routine dental exams. Routine vision and hearing exams are available for copays of $50 and $55 respectively, alongside partial coverage for contacts and prescription hearing aids. Skilled nursing facility stays are also covered with no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
Medicare BlueVital (PPO) covers inpatient acute hospital stays with no coinsurance and a $475 daily copay for days 1 through 5, and psychiatric stays with no coinsurance and a $407 daily copay for days 1 through 5. Both services require prior authorization and offer no copay for days 6 through 90, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Medicare BlueVital (PPO) covers outpatient hospital and ambulatory surgical center services with a $450 copay and no coinsurance. Outpatient substance abuse services require no copay but have 20% coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Medicare BlueVital (PPO) covers partial hospitalization services with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Medicare BlueVital (PPO), requiring prior authorization and a $150 copay with no coinsurance for ground and air ambulance services. Transportation services to plan-approved or any other health-related locations are not covered.
Emergency Services See details
Medicare BlueVital (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 23 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays ranging from $40 to $150.
Primary Care See details
Medicare BlueVital (PPO) covers primary care physician visits for a $10 copay and specialist visits for a $55 copay, both with no coinsurance. Chiropractic services are partially covered, with routine and other chiropractic care not covered, while podiatry services are not covered. Mental health and psychiatric services are covered with no copay and 20% coinsurance.
Preventive Services See details
Preventive services are partially covered under Medicare BlueVital (PPO) with no copay and no coinsurance for covered services such as annual physical exams, kidney disease education, and glaucoma screenings. However, several supplemental services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management programs, and counseling.
Hearing Services See details
Hearing services under Medicare BlueVital (PPO) include one annual routine exam for a $55 copay, no coinsurance, and no deductible, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay between $499 and $799 for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Medicare BlueVital (PPO) with no deductible, offering one routine eye exam per year for a $50 copay and no coinsurance, while other eye exams are not covered. Eyewear is also partially covered up to a $250 annual limit with no coinsurance and a $55 copay for contact lenses, though eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Medicare BlueVital (PPO) partially covers dental services, offering Medicare-covered dental care for a $55 copay and no coinsurance, alongside routine exams, cleanings, and x-rays with no copay and no coinsurance. However, other sub-services such as fluoride, restorative care, endodontics, periodontics, and prosthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Medicare BlueVital (PPO) with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by Medicare BlueVital (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medicare BlueVital (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, with prior authorization required. Covered diabetic supplies carry a $5 copay and no coinsurance, while diabetic therapeutic shoes and inserts require a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Medicare BlueVital (PPO) with prior authorization, featuring a $15 copay and no coinsurance for diagnostic tests, procedures, and lab services. Outpatient x-rays require a $55 copay, diagnostic radiological services require a $300 copay, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home health services are covered under Medicare BlueVital (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered by Medicare BlueVital (PPO) with a $15 copay and no coinsurance for covered services, including additional cardiac rehabilitation and Medicare-covered Supervised Exercise Therapy (SET) for symptomatic peripheral artery disease. Standard cardiac rehabilitation, intensive cardiac rehabilitation, and pulmonary rehabilitation services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
Medicare BlueVital (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other services under Medicare BlueVital (PPO) are partially covered, featuring acupuncture with no copay and a 50% coinsurance for up to 10 treatments per year. Over-the-counter (OTC) items and meal benefits are not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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