2022 Medicare Blue Choice Select (HMO)

Medicare Blue Choice Select (HMO) H3351-016 is a 2022 Medicare Advantage Plan or Part-C by Excellus Health Plan, Inc available to residents in New York. This plan includes additional prescription drug (Part-D) coverage. The Medicare Blue Choice Select (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

Medicare Blue Choice Select (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Excellus Health Plan, Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Medicare Blue Choice Select (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Excellus Health Plan, Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Excellus Health Plan, Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Excellus Health Plan, Inc Medicare Advantage Plan Costs

Medicare Blue Choice Select (HMO) Part-C Premium

Excellus Health Plan, Inc charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H3351-016 Part-D Deductible and Premium

Medicare Blue Choice Select (HMO) has a monthly drug premium of $0.00 and a $380.00 drug deductible. This Excellus Health Plan, Inc plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Excellus Health Plan, Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Excellus Health Plan, Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Excellus Health Plan, Inc plan does not offer additional coverage through the gap.

H3351-016 Formulary or Drug Coverage

Medicare Blue Choice Select (HMO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Medicare Blue Choice Select (HMO) H3351-016 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$15	$20
Tier 3	$42	$47
Tier 4	$95	$100
Tier 5	26%	26%

*Initial Coverage Phase and 30 day supply

2021 Medicare Blue Choice Select (HMO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

Yes

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$275 copay
Diagnostic tests and procedures	$12 copay
Lab services	$12 copay
Outpatient x-rays	$55 copay

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Doctor Visits

Primary	$15 copay per visit
Specialist	$50 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$45 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$50 copay
Routine foot care	Not covered

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Ground Ambulance

$250 copay

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Hearing

Fitting/evaluation	$0 copay
Hearing aids	$699-999 copay
Hearing exam	$50 copay

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Inpatient Hospital Coverage

$395 per day for days 1 through 5 $0 per day for days 6 through 90

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Medical Equipment/Supplies

Diabetes supplies	$5 copay per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$315 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit	20% coinsurance
Outpatient group therapy visit with a psychiatrist	20% coinsurance
Outpatient individual therapy visit	20% coinsurance
Outpatient individual therapy visit with a psychiatrist	20% coinsurance

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MOOP

$7,550 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

20% coinsurance per visit

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Package #1

Deductible	$100.00
Monthly Premium	$39.00

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Preventive Care

$0 copay

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Preventive Dental

Cleaning	Not covered
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	Not covered

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Rehabilitation Services

Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	$50 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Medicare Blue Choice Select (HMO) H3351

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Medicare Blue Choice Select (HMO) Plans Performance

Health Plan Customer Service Rating for Medicare Blue Choice Select (HMO)

Medicare Blue Choice Select (HMO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Medicare Blue Choice Select (HMO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.