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This is an important legal document. Keep it in a safe place.  \nThis document explains your benefits and rights. Use this document to understand:  \nOur plan premium and cost sharing  \nOur medical and drug benefits  \nHow to file a complaint if you’re not satisfied with a service or treatment  \nHow to contact us  \nOther protections required by Medicare law  \nFor 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.  \nThis 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).)  \nThis information is also available in braille, large print, or other alternate formats.  \nBenefits, 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.  \nH3335_ 10888_CMCC-53Y26  \nOMB Approval 0938-1051(Expires: August 31, 2026)  \n2026 Evidence of Coverage for Medicare BlueBalanced PPO 1  \nTable of Contents  \nTable of Contents  \nChapter 1. Get Started as a Member......................................................................... 5  \nSECTION 1 You’re a member of Medicare BlueBalanced (PPO) .....................................5  \nSECTION 2 Plan eligibility requirements..................................................................... 5  \nSECTION 3 Important membership materials..............................................................6  \nSECTION 4 Summary of Important Costs for 2026...................................................... 7  \nSECTION 5 More information about your monthly plan premium................................ 13  \nSECTION 6 Keep our plan membership record up to date.......................................... 15  \nSECTION 7 How other insurance works with our plan................................................15  \nChapter 2. Phone numbers and resources............................................................... 19  \nSECTION 1 Medicare BlueBalanced (PPO) contacts....................................................19  \nSECTION 2 Get help from Medicare..........................................................................21  \nSECTION 3 State Health Insurance Assistance Program (SHIP) .................................. 22  \nSECTION 4 Quality Improvement Organization......................................................... 23  \nSECTION 5 Social Security.......................................................................................23  \nSECTION 6 Medicaid............................................................................................... 24  \nSECTION 7 Programs to help people pay for prescription drugs................................. 24  \nSECTION 8 Railroad Retirement Board (RRB) ............................................................28  \nSECTION 9 If you have group insurance or other health insurance from an employer..28  \nChapter 3. Using our plan for your medical services............................................... 30  \nSECTION 1 How to get medical care as a member of our plan................................... 30  \nSECTION 2 Use network and out-of-network providers to get medical care.................31  \nSECTION 3 How to get services in an emergency, disaster, or ","cbCainSRgOFIgqlO","https://ap.wps.com/l/cbCainSRgOFIgqlO","pdf",866532,205,"English","# Chapter 1. Get Started as a Member\n## SECTION 1 You’re a member of Medicare BlueBalanced (PPO)\n## SECTION 2 Plan eligibility requirements\n## SECTION 3 Important membership materials\n## SECTION 4 Summary of Important Costs for 2026\n## SECTION 5 More information about your monthly plan premium\n## SECTION 6 Keep our plan membership record up to date\n## SECTION 7 How other insurance works with our plan\n# Chapter 2. Phone numbers and resources\n## SECTION 1 Medicare BlueBalanced (PPO) contacts\n## SECTION 2 Get help from Medicare\n## SECTION 3 State Health Insurance Assistance Program (SHIP)\n## SECTION 4 Quality Improvement Organization\n## SECTION 5 Social Security\n## SECTION 6 Medicaid\n## SECTION 7 Programs to help people pay for prescription drugs\n## SECTION 8 Railroad Retirement Board (RRB)\n## SECTION 9 If you have group insurance or other health insurance from an employer\n# Chapter 3. Using our plan for your medical services\n## SECTION 1 How to get medical care as a member of our plan\n## SECTION 2 Use network and out-of-network providers to get medical care\n## SECTION 3 How to get services in an emergency, disaster, or urgent need for care\n## SECTION 4 What if you’re billed directly for the full cost of your covered services?\n## SECTION 5 Medical services in a clinical research study\n## SECTION 6 Rules for getting care in a religious non-medical health care institution\n## SECTION 7 Rules for ownership of durable medical equipment\n# Chapter 4. Medical Benefits Chart (what's covered and what you pay)\n## SECTION 1 Understanding your out-of-pocket costs for covered services\n## SECTION 2 The Medical Benefits Chart shows your medical benefits and costs\n## SECTION 3 Services that aren’t covered by our plan (exclusions)\n# Chapter 5. Using plan coverage for Part D drugs\n## SECTION 1 Basic rules for our plan’s Part D drug coverage\n## SECTION 2 Fill your prescription at a network pharmacy or through our plan’s mail order service\n## SECTION 3 Your drugs need to be on our plan’s Drug List\n## SECTION 4 Drugs with restrictions on coverage\n## SECTION 5 What you can do if one of your drugs isn’t covered the way you’d like\n## SECTION 6 Our Drug List can change during the year\n## SECTION 7 Types of drugs we don’t cover\n## SECTION 8 How to fill a prescription\n## SECTION 9 Part D drug coverage in special situations","[{\"question\":\"What period does this Evidence of Coverage cover, and what does it explain?\",\"answer\":\"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.\"},{\"question\":\"How are plan premiums, deductibles, and cost sharing handled in 2026?\",\"answer\":\"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.\"},{\"question\":\"How do members access Part D drug coverage and fill prescriptions?\",\"answer\":\"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.\"}]","Evidence of Coverage for 2026: Medicare BlueBalanced (PPO) - Your Medicare Health Benefits, Services, and Drug Coverage | PDF",1790554672,517]