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Medicare Blue Choice Extra (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare Blue Choice Extra (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare Blue Choice Extra (HMO) in 2025, please refer to our full plan details page.
Medicare Blue Choice Extra (HMO) is a HMO plan offered by Lifetime Healthcare, Inc. available for enrollment in 2025 to people living in Metro Rochester Area. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Medicare Blue Choice Extra (HMO) 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 Blue Choice Extra (HMO).
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 Blue Choice Extra (HMO), 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 $26.00. 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 $400.00 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 Maximum Out-Of-Pocket cost of $9300.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network 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 Blue Choice Extra (HMO) plan has a $400 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $15 copay at preferred pharmacies. For preferred brand drugs and non-preferred drugs, you will pay 50% and 28% coinsurance, respectively. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for your Part D covered drugs.
Additional Benefits
The Medicare Blue Choice Extra (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, and outpatient services. You will pay a copay for primary care, specialist visits, and some outpatient services. The plan also covers preventive services, hearing, vision, dental, and home health services. This plan includes coverage for ambulance services, emergency services, and some mental health services. You will pay a copay for emergency services, and a coinsurance for mental health services. The plan also offers coverage for medical equipment and diagnostic services, with varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric, are covered with prior authorization. For Inpatient Hospital-Acute, you have a $475 copay for days 1-5, and no copay for days 6-90; additional days are covered with no copay. Inpatient Hospital Psychiatric has a $407 copay for days 1-5, and no copay for days 6-90; additional days and non-Medicare-covered stays 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 copay of $400.00. Outpatient Substance Abuse Services, including individual and group sessions, have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
The Medicare Blue Choice Extra (HMO) plan covers ambulance services with no coinsurance, but there is a $275 copay for both ground and air ambulance services. 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 Blue Choice Extra (HMO) plan. For Emergency Services and Worldwide Emergency Coverage, there is a $110 copay, and for Worldwide Emergency Transportation, there is a $275 copay, while Urgently Needed Services and Worldwide Urgent Coverage have a $45 copay.
Primary Care See details
The Medicare Blue Choice Extra (HMO) plan covers Primary Care Physician Services with a $10 copay, Chiropractic Services with a $15 copay, and Occupational Therapy Services with a $35 copay. Physician Specialist Services have a $50 copay, and Physical Therapy and Speech-Language Pathology Services have a $35 copay. Mental Health and Psychiatric Services have a 20% coinsurance. Additional Telehealth Benefits have a 20% coinsurance and a copay between $0 and $50. Opioid Treatment Program Services have a 20% coinsurance. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered preventive services, annual physical exams, and additional preventive services, with no copay. Additional services like in-home safety assessments, personal emergency response systems, and others are not covered.
Hearing Services See details
Hearing Services are covered, including Routine Hearing Exams with a $50 copay per visit, and Fitting/Evaluation for Hearing Aid with no copay. Prescription Hearing Aids (all types) are covered with a copay between $499 and $799 per visit. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision Services are covered, including routine eye exams and eyewear. Routine eye exams and eyewear have a $50 copay, and the plan covers contact lenses, eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Medicare Blue Choice Extra (HMO) plan covers dental services, including oral exams with a $50 copay, dental x-rays, and prophylaxis (cleaning) with a $50 copay. Orthodontic services are covered up to a maximum of $1000 per year, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Medicare Blue Choice Extra (HMO) plan. 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 Blue Choice Extra (HMO) plan. There is a coinsurance of 20% for these services.
Medical Equipment See details
The Medicare Blue Choice Extra (HMO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance, and Prosthetic Devices and Medical Supplies with a 20% coinsurance. Diabetic Supplies have a $5 copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests and lab services, are covered under the Medicare Blue Choice Extra (HMO) plan, with a $15 copay for diagnostic procedures/tests and a $15 copay for lab services. Outpatient X-ray services have a $55 copay, while diagnostic radiological services have a $300 copay, and therapeutic radiological services have 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Medicare Blue Choice Extra (HMO) plan with no copay and no coinsurance, but prior authorization is required. 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 Blue Choice Extra (HMO) 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 by Medicare Blue Choice Extra (HMO). For days 1-20, there is no copay, while days 21-100 have a $214 copay; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Medicare Blue Choice Extra (HMO) plan covers acupuncture with 50% coinsurance, and up to 10 treatments per year. Over-the-counter items are also covered, with a maximum benefit of $50 every three months, including nicotine replacement therapy, but not Naloxone. 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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