Medicare Blue Dual (HMO D-SNP)
Available to residents of Monroe County, NY for 2027. Contract H7524, plan 003, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Monroe County
- Plan website
- Browse the Medicare Blue Dual (HMO D-SNP) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed for 2027. CMS carries this plan forward from 2026. Every NY plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $23.70 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $23.70? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | $135.00 |
| In-network out-of-pocket maximum | $9,850.00? |
| Drug deductible | $700.00Tier 1 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| D-SNP integration status | Highly Integrated (HIDE) |
| Zero-dollar cost sharing D-SNP | Yes |
| Contract / plan | H7524-003-0 |
| Offered by | Excellus Health Plan Community Care LLC |
| Parent organization | Lifetime Healthcare, Inc. |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.ExcellusBCBS.com |
| Member services | (800)659-1986TTY 711 |
CMS star ratings
- Overall
- 3 out of 5 stars for Overall
- Health plan (Part C)
- 3 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H7524 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | 30% coinsurance |
| Specialist | 30% coinsurance |
| Other health care professional | 30% coinsurance |
| Additional telehealth services | $0 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay(authorization required) |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | 30% coinsurance |
| Diabetes self-management training | 30% coinsurance |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 30% coinsurance(authorization required) |
| Lab services | 30% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | 30% coinsurance(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | 30% coinsurance(authorization required) |
| Emergency and urgent care | |
| Emergency room | 20% coinsurance |
| Urgent care | 30% coinsurance |
| Worldwide emergency coverage | 20% coinsurance |
| Worldwide urgent care | 30% coinsurance |
| Worldwide emergency transportation | 30% coinsurance |
| Hospital care | |
| Inpatient hospital stay | $2,241 per stay(authorization required) |
| Outpatient hospital services | 30% coinsurance(authorization required) |
| Outpatient observation | 30% coinsurance |
| Ambulatory surgical center | 30% coinsurance(authorization required) |
| Outpatient blood services | 30% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $221 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | 30% coinsurance |
| Physical therapy and speech-language therapy | 30% coinsurance(authorization required) |
| Cardiac rehabilitation | 30% coinsurance |
| Pulmonary rehabilitation | 30% coinsurance |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $2,091 per stay(authorization required) |
| Outpatient mental health, individual session | 30% coinsurance |
| Outpatient mental health, group session | 30% coinsurance |
| Psychiatrist, individual session | 30% coinsurance |
| Psychiatrist, group session | 30% coinsurance |
| Partial hospitalization | 30% coinsurance |
| Intensive outpatient program | 30% coinsurance |
| Outpatient substance use, individual session | 30% coinsurance |
| Outpatient substance use, group session | 30% coinsurance |
| Opioid treatment program | 30% coinsurance |
| Ambulance and transportation | |
| Ground ambulance | 30% coinsurance(authorization required) |
| Air ambulance | 30% coinsurance(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | 30% coinsurance |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | 30% coinsurance |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | 30% coinsurance |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(authorization required) |
| Other diagnostic dental services | $0 copay(authorization required) |
| Other preventive dental services | $0 copay(authorization required) |
| Restorative services (fillings, crowns) | $0 copay(authorization required) |
| Endodontics (root canals) | $0 copay(authorization required) |
| Periodontics (gum disease) | $0 copay(authorization required) |
| Dentures and other removable prosthodontics | $0 copay(authorization required) |
| Maxillofacial prosthetics | $0 copay(authorization required) |
| Implants | $0 copay(authorization required) |
| Bridges and other fixed prosthodontics | $0 copay(authorization required) |
| Oral and maxillofacial surgery | $0 copay(authorization required) |
| Orthodontics | $0 copay(authorization required) |
| Adjunctive general services | $0 copay(authorization required) |
| Vision? | |
| Eye exam (Medicare-covered) | 30% coinsurance |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | 30% coinsurance(limits apply) |
| Eyewear plan limit | $200 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | 30% coinsurance |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $0 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $75 allowance every month |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $10.00 |
| Tier 3 · Preferred Brand | $40.00 |
| Tier 4 · Non-Preferred Drug | 25% |
| Tier 5 · Specialty Tier | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $10.00 | $10.00 | $10.00 | $30.00 | $30.00 | $30.00 |
| Tier 3: Preferred Brand | $40.00 | $40.00 | $40.00 | $120.00 | $120.00 | $120.00 |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | 25% | 25% | 25% |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 2 out of 5 stars for Breast Cancer Screening | Plan too small to be measured |
| Colorectal Cancer Screening · C02 | 2 out of 5 stars for Colorectal Cancer Screening | Plan too small to be measured |
| Annual Flu Vaccine · C03 | 2 out of 5 stars for Annual Flu Vaccine | Plan too small to be measured |
| Managing Chronic (Long Term) Conditions | ||
| Special Needs Plan (SNP) Care Management · C07 | 2 out of 5 stars for Special Needs Plan (SNP) Care Management | 4 out of 5 stars for Special Needs Plan (SNP) Care Management |
| Care for Older Adults – Medication Review · C08 | 2 out of 5 stars for Care for Older Adults – Medication Review | not enough data |
| Care for Older Adults - Functional Status Assessment · C09 | 1 out of 5 stars for Care for Older Adults - Functional Status Assessment | new measure |
| Diabetes Care – Eye Exam · C11 | 2 out of 5 stars for Diabetes Care – Eye Exam | Plan too small to be measured |
| Diabetes Care – Blood Sugar Controlled · C12 | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled | Plan too small to be measured |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 2 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | Plan too small to be measured |
| Controlling High Blood Pressure · C14 | 1 out of 5 stars for Controlling High Blood Pressure | Plan too small to be measured |
| Plan All-Cause Readmissions · C17 | 1 out of 5 stars for Plan All-Cause Readmissions | Plan too small to be measured |
| Statin Therapy for Patients with Cardiovascular Disease · C18 | 1 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease | Plan too small to be measured |
| Transitions of Care · C19 | 4 out of 5 stars for Transitions of Care | Plan too small to be measured |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 3 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | Plan too small to be measured |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 3 out of 5 stars for Getting Needed Care | Plan too small to be measured |
| Customer Service · C23 | 3 out of 5 stars for Customer Service | Plan too small to be measured |
| Rating of Health Care Quality · C24 | 4 out of 5 stars for Rating of Health Care Quality | Plan too small to be measured |
| Rating of Health Plan · C25 | 5 out of 5 stars for Rating of Health Plan | Plan too small to be measured |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 2 out of 5 stars for Complaints about the Health Plan | not enough data |
| Members Choosing to Leave the Plan · C28 | 4 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 2 out of 5 stars for Complaints about the Drug Plan | not enough data |
| Members Choosing to Leave the Plan · D03 | 4 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| Drug Plan Quality Improvement · D04 | 2 out of 5 stars for Drug Plan Quality Improvement | not enough data |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 5 out of 5 stars for Rating of Drug Plan | Plan too small to be measured |
| Getting Needed Prescription Drugs · D06 | 4 out of 5 stars for Getting Needed Prescription Drugs | Plan too small to be measured |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 4 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 2 out of 5 stars for Medication Adherence for Diabetes Medications | 1 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 2 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 3 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 1 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | not enough data |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 4 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 1 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H7524 shares it.
Also available in 10 other NY counties
Benefits in plain text
Medicare Blue Dual (HMO D-SNP) (H7524-003-0) is a 2027 HMO D-SNP Medicare Advantage plan offered by Excellus Health Plan Community Care LLC, available to residents of Monroe County, NY.
The monthly premium is $23.70.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
The in-network deductible for health services is $135.00.
Its in-network out-of-pocket maximum is $9,850.00.
The drug deductible is $700.00. Tier 1 exempt.
It is a special needs plan (Dual-eligible SNP).
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $10.00; tier 3 (Preferred Brand): $40.00; tier 4 (Non-Preferred Drug): 25%; tier 5 (Specialty Tier): 25%.
CMS gives the plan's contract (H7524) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.