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Medicare BlueBalanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare BlueBalanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare BlueBalanced (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 BlueBalanced (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 BlueBalanced (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 BlueBalanced (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 BlueBalanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $55.00. 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 $8000.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8000.00 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 $11300.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $11300.00 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 BlueBalanced (PPO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generics, you will pay as little as a $3 copay for a one-month supply at preferred pharmacies, while Tier 2 generics start at a $15 copay. Standard pharmacies and mail-order options are also available with slightly higher copayments. Brand-name and specialty medications are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 22% to 25% coinsurance, while Tier 4 non-preferred drugs range from 25% to 50% coinsurance. Tier 5 specialty drugs carry a flat 25% coinsurance across all pharmacy and mail-order options.
Additional Benefits
Medicare BlueBalanced (PPO) offers comprehensive healthcare coverage with affordable copays for your core medical needs. Members pay a low $5 copay for primary care visits and a $40 copay for specialists, while preventive care services are available with no copay and no coinsurance. For major medical care, inpatient hospital stays require a $400 daily copay for days one through five with no copay thereafter, and outpatient services carry a $350 copay. Supplemental benefits include routine dental exams, cleanings, and annual routine eye exams with no copay and no coinsurance. Routine hearing exams require a $40 copay, and the plan offers eyewear coverage up to a $250 annual limit alongside partial coverage for prescription hearing aids. Additionally, home health services feature no copay, and skilled nursing facility care has no copay for the first 20 days.
Inpatient Hospital See details
Medicare BlueBalanced (PPO) covers inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. For acute stays, you pay a $400 daily copay for days 1 through 5 and no copay for days 6 and beyond, while psychiatric stays require a $375 daily copay for days 1 through 5 and no copay for days 6 through 90. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Medicare BlueBalanced (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 have no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered under the Medicare BlueBalanced (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to access these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Medicare BlueBalanced (PPO), which features a $150 copay and no coinsurance for ground and air ambulance services, subject to prior authorization. However, transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Medicare BlueBalanced (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 23 hours. Urgently needed services require a $40 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $115, $40, and $150 respectively.
Primary Care See details
Medicare BlueBalanced (PPO) offers primary care physician visits for a $5 copay and no coinsurance, specialist visits for a $40 copay and no coinsurance, and physical and occupational therapy for a $35 copay and no coinsurance. Mental health, psychiatric, and opioid treatment services feature no copay and a 20% coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered under Medicare BlueBalanced (PPO) with no copay and no coinsurance for covered services such as annual physical exams, kidney disease education, and diabetes self-management. Sub-services that are not covered include health education, in-home safety assessments, personal emergency response systems, 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, additional smoking cessation counseling, enhanced disease management, telemonitoring, home modifications, and counseling.
Hearing Services See details
Medicare BlueBalanced (PPO) covers hearing services with no deductible, including one annual routine exam for a $40 copay and no coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $499 to $799 for up to two devices per year, while OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Medicare BlueBalanced (PPO) partially covers vision services, offering one routine eye exam annually with no copay and no coinsurance, while other eye exams are not covered. Eyewear is covered up to a $250 annual limit with no coinsurance and a $40 copay for contact lenses, but eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Medicare BlueBalanced (PPO) partially covers dental services, providing Medicare-covered dental care with a $40.00 copay and no coinsurance, as well as routine exams, cleanings, and x-rays with no copay and no coinsurance. Other dental services are not covered, including fluoride treatments, restorative care, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics.
Home Infusion bundled Services See details
Medicare BlueBalanced (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Medicare BlueBalanced (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Medicare BlueBalanced (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, subject to prior authorization. Diabetic supplies are covered with a $5 copay, while diabetic therapeutic shoes and inserts carry a 20% coinsurance, with both requiring prior authorization and limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Medicare BlueBalanced (PPO) with prior authorization required. Diagnostic procedures and lab services require a $10 copay and no coinsurance, while radiological services require a $50 copay for X-rays, a minimum $250 copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by Medicare BlueBalanced (PPO) with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered by Medicare BlueBalanced (PPO) with no coinsurance and a $15 copay for applicable services. However, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Medicare BlueBalanced (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare limit are not covered.
Other Services See details
Medicare BlueBalanced (PPO) partially covers other services, offering acupuncture with no copay and a 50% coinsurance for up to 10 treatments every year. Over-the-counter (OTC) items and meal benefits are not covered under this plan.
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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