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Medicare Blue Choice Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare Blue Choice Prime (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 Prime (HMO) in 2026, please refer to our full plan details page.
Medicare Blue Choice Prime (HMO) is a HMO plan offered by Lifetime Healthcare, Inc. available for enrollment in 2026 to people living in Greater Rochester Area. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Medicare Blue Choice Prime (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 Prime (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 Prime (HMO), 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. 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 $8000.00 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 Prime (HMO) prescription drug plan has an annual drug deductible of $615. During the initial coverage phase, Tier 1 preferred generic drugs cost as little as a $4 copay for a one-month supply at preferred pharmacies and preferred mail order, while standard pharmacies charge a $9 copay. Tier 2 generic medications are also available with a $15 copay for a one-month supply at preferred pharmacies and a $20 copay at standard pharmacies. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 21% coinsurance at preferred pharmacies and a 25% coinsurance at standard pharmacies. Tier 4 non-preferred drugs carry a 25% coinsurance at preferred locations and 50% at standard locations, while Tier 5 specialty drugs require a flat 25% coinsurance across all pharmacy options.
Additional Benefits
The Medicare Blue Choice Prime (HMO) plan offers robust medical coverage with predictable copays and no coinsurance for many essential services. Primary care visits require a low $5 copay, specialist visits cost $40, and emergency room care is available for a $115 copay. For hospital stays, members pay a daily copay of $400 for the first five days of acute inpatient care, followed by no copay for additional days. Routine preventive services, annual physicals, routine eye exams, and preventive dental cleanings are fully covered with no copay and no coinsurance. The plan also features partial coverage for specialty care, offering a $215 annual allowance for eyewear and up to two prescription hearing aids per year with copays between $499 and $799. Other services, such as home health care, require no copay, while durable medical equipment and dialysis carry a 20% coinsurance.
Inpatient Hospital See details
Medicare Blue Choice Prime (HMO) covers inpatient hospital services with no coinsurance, requiring a $400 daily copay for days 1 through 5 of acute stays and a $375 daily copay for days 1 through 5 of psychiatric stays, followed by no copay for remaining days. Additional acute days are unlimited at no copay, though upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Medicare Blue Choice Prime (HMO) covers outpatient hospital, observation, and ambulatory surgical center services with a $350 copay and no coinsurance. Outpatient substance abuse services require a 20% coinsurance with no copay, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Medicare Blue Choice Prime (HMO) covers partial hospitalization services with no copay and a 20% coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Medicare Blue Choice Prime (HMO), offering ground and air ambulance services with a $150 copay and no coinsurance, subject to prior authorization. However, transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
Medicare Blue Choice Prime (HMO) 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 have a $40 copay and no coinsurance, while worldwide emergency services are covered with no coinsurance and copays of $115 for emergency care, $40 for urgent care, and $150 for emergency transportation.
Primary Care See details
Medicare Blue Choice Prime (HMO) covers primary care visits for a $5 copay and specialist visits for a $40 copay, both with no coinsurance. Physical and occupational therapies require a $35 copay and no coinsurance, while mental health, psychiatric, and opioid treatments have no copay and 20% coinsurance. Podiatry is not covered, and although some chiropractic services are covered, routine and other chiropractic services are not covered.
Preventive Services See details
Medicare Blue Choice Prime (HMO) covers preventive services, including annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance, excluding health education, in-home safety assessments, personal emergency response systems, and medical nutrition therapy, while covering memory fitness and remote access technologies.
Hearing Services See details
Medicare Blue Choice Prime (HMO) partially covers hearing services with no deductible, offering routine hearing exams for a $40 copay and no coinsurance. Up to two prescription hearing aids are covered per year with a copay ranging from $499 to $799 and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
Medicare Blue Choice Prime (HMO) partially covers vision services, providing one routine eye exam annually with no copay and no coinsurance, while other eye exam services are not covered. Eyewear is also partially covered up to a $215 annual limit with no coinsurance and a $40 copay for contact lenses, though individual eyeglass lenses, eyeglass frames, and upgrades are excluded.
Dental Services See details
Medicare Blue Choice Prime (HMO) partially covers dental services, offering Medicare-covered dental care for a $40 copay and no coinsurance. Preventive services including oral exams, cleanings, and X-rays are covered with no copay and no coinsurance, while fluoride, restorative, endodontic, periodontic, prosthodontic, implant, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Medicare Blue Choice Prime (HMO) with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Medicare Blue Choice Prime (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medicare Blue Choice Prime (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance. Diabetic supplies are covered with a $5 copay and no coinsurance, while diabetic therapeutic shoes and inserts carry a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Medicare Blue Choice Prime (HMO) covers diagnostic procedures, tests, and lab services with a $10 copay and no coinsurance, requiring prior authorization. Diagnostic radiological services carry a $250 copay, outpatient X-rays require a $50 copay, and therapeutic radiological services have a 20% coinsurance, with prior authorization required for all radiological services.
Home Health Services See details
Medicare Blue Choice Prime (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered by Medicare Blue Choice Prime (HMO) with no coinsurance and a $15.00 copayment for certain services, though standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Medicare Blue Choice Prime (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, 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, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Medicare Blue Choice Prime (HMO) offers other services that are partially covered, featuring acupuncture with no copay and a 50% coinsurance for up to 10 treatments per year. Over-the-counter (OTC) items, meal benefits, and dual eligible SNPs are not covered.
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