Evidence of Coverage for 2026: Medicare BlueBalanced (PPO) - Your Medicare Health Benefits, Services, and Drug Coverage

Sep 28, 2026

Details Medicare health and drug coverage for members of Medicare BlueBalanced (PPO) for January 1–December 31, 2026. Covers plan premium and cost sharing, medical and Part D drug benefits, and guidance on filing complaints, contacting the plan, and understanding required Medicare protections. Includes membership materials, eligibility requirements, key dates and change notices for 2027, plus a structured roadmap through chapters on care access, provider networks, medical benefits, and Part D pharmacy rules.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages205

Reading Time8 h 37 min

AccessFree to download

Chapter 1. Get Started as a Member

SECTION 1 You’re a member of Medicare BlueBalanced (PPO)

SECTION 2 Plan eligibility requirements

SECTION 3 Important membership materials

SECTION 4 Summary of Important Costs for 2026

SECTION 5 More information about your monthly plan premium

SECTION 6 Keep our plan membership record up to date

SECTION 7 How other insurance works with our plan

Chapter 2. Phone numbers and resources

SECTION 1 Medicare BlueBalanced (PPO) contacts

SECTION 2 Get help from Medicare

SECTION 3 State Health Insurance Assistance Program (SHIP)

SECTION 4 Quality Improvement Organization

SECTION 5 Social Security

SECTION 6 Medicaid

SECTION 7 Programs to help people pay for prescription drugs

SECTION 8 Railroad Retirement Board (RRB)

SECTION 9 If you have group insurance or other health insurance from an employer

Chapter 3. Using our plan for your medical services

SECTION 1 How to get medical care as a member of our plan

SECTION 2 Use network and out-of-network providers to get medical care

SECTION 3 How to get services in an emergency, disaster, or urgent need for care

SECTION 4 What if you’re billed directly for the full cost of your covered services?

SECTION 5 Medical services in a clinical research study

SECTION 6 Rules for getting care in a religious non-medical health care institution

SECTION 7 Rules for ownership of durable medical equipment

Chapter 4. Medical Benefits Chart (what's covered and what you pay)

SECTION 1 Understanding your out-of-pocket costs for covered services

SECTION 2 The Medical Benefits Chart shows your medical benefits and costs

SECTION 3 Services that aren’t covered by our plan (exclusions)

Chapter 5. Using plan coverage for Part D drugs

SECTION 1 Basic rules for our plan’s Part D drug coverage

SECTION 2 Fill your prescription at a network pharmacy or through our plan’s mail order service

SECTION 3 Your drugs need to be on our plan’s Drug List

SECTION 4 Drugs with restrictions on coverage

SECTION 5 What you can do if one of your drugs isn’t covered the way you’d like

SECTION 6 Our Drug List can change during the year

SECTION 7 Types of drugs we don’t cover

SECTION 8 How to fill a prescription

SECTION 9 Part D drug coverage in special situations

A nonprofit independent licensee of the Blue Cross Blue Shield Association January 1-December 31, 2026 Evidence of Coverage for 2026: Your Medicare Health Benefits and Services and Drug Coverage asa Member of Medicare BlueBalanced (PPO) This document gives the details of your Medicare health and drug coverage from January 1 – December 31, 2026. This is an important legal document. Keep it in a safe place. This document explains your benefits and rights. Use this document to understand: Our plan premium and cost sharing Our medical and drug benefits How to file a complaint if you’re not satisfied with a service or treatment How to contact us Other protections required by Medicare law For questions about this document call Customer Care at 1-877-883-9577 (TTY/TDD users call 711). Hours are Monday-Friday, 8:00 a.m. -8:00 p.m. Representatives are also available 8:00 a.m. -8:00 p.m., Monday-Sunday, from October 1-March 31.) This call is free. This plan, Medicare BlueBalanced (PPO), is offered by Excellus BlueCross BlueShield. (When this Evidence of Coverage says “we,”“us,” or “our” it means Excellus BlueCross BlueShield. When it says“plan” or “our plan”, it means Medicare BlueBalanced (PPO).) This information is also available in braille, large print, or other alternate formats. Benefits, premiums, deductibles, and/or copayment/coinsurance may change on January 1, 2027. Our formulary, pharmacy network, and/or provider network can change at any time. You’ll get notice about any changes that can affect you at least 30 days in advance. H3335_ 10888_CMCC-53Y26 OMB Approval 0938-1051(Expires: August 31, 2026) 2026 Evidence of Coverage for Medicare BlueBalanced PPO 1 Table of Contents Table of Contents Chapter 1. Get Started as a Member......................................................................... 5 SECTION 1 You’re a member of Medicare BlueBalanced (PPO) .....................................5 SECTION 2 Plan eligibility requirements..................................................................... 5 SECTION 3 Important membership materials..............................................................6 SECTION 4 Summary of Important Costs for 2026...................................................... 7 SECTION 5 More information about your monthly plan premium................................ 13 SECTION 6 Keep our plan membership record up to date.......................................... 15 SECTION 7 How other insurance works with our plan................................................15 Chapter 2. Phone numbers and resources............................................................... 19 SECTION 1 Medicare BlueBalanced (PPO) contacts....................................................19 SECTION 2 Get help from Medicare..........................................................................21 SECTION 3 State Health Insurance Assistance Program (SHIP) .................................. 22 SECTION 4 Quality Improvement Organization......................................................... 23 SECTION 5 Social Security.......................................................................................23 SECTION 6 Medicaid............................................................................................... 24 SECTION 7 Programs to help people pay for prescription drugs................................. 24 SECTION 8 Railroad Retirement Board (RRB) ............................................................28 SECTION 9 If you have group insurance or other health insurance from an employer..28 Chapter 3. Using our plan for your medical services............................................... 30 SECTION 1 How to get medical care as a member of our plan................................... 30 SECTION 2 Use network and out-of-network providers to get medical care.................31 SECTION 3 How to get services in an emergency, disaster, or

FAQs

What period does this Evidence of Coverage cover, and what does it explain?

It covers Medicare BlueBalanced (PPO) coverage from January 1 through December 31, 2026. It explains benefits, costs, rights, and member protections, including how to contact the plan and file complaints.

How are plan premiums, deductibles, and cost sharing handled in 2026?

The document describes plan premium and cost sharing, and provides a Summary of Important Costs for 2026 plus a Medical Benefits Chart showing what is covered and what members pay.

How do members access Part D drug coverage and fill prescriptions?

Part D rules include using network pharmacies or the plan’s mail-order service and ensuring drugs are on the plan’s Drug List. The document also covers restrictions on coverage and what to do when a drug isn’t covered as you prefer.

Sep 28, 2026

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