Complete Blue PPO Distinct (PPO)
Health Insurance Company: Highmark Blue Cross Blue Shield or Highmark Blue Shield
Medicare Advantage Plan Details
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $10 copay per visit
Out-of-network: $0 copay
Emergency Room
$100 copay per visit (always covered)
Ambulance Coverage
In-network: $275 copay
Out-of-network: $275 copay or 30% coinsurance
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0 copay
Out-of-network: $0 copay
Medicare-covered lab services: In-network: $0 copay
Out-of-network: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $175 copay
Out-of-network: $175 copay
Medicare-covered x-ray services: In-network: $20 copay
Out-of-network: $20 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $200 copay per visit
Out-of-network: $200 copay per visit
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $225 per stay
Out-of-network: $225 per stay
Inpatient hospital psychiatric:
In-network: $425 per day for days 1 through 3
$0 per day for days 4 through 90
Out-of-network: $475 per day for days 1 through 3
$0 per day for days 4 through 90
Rehabilitation Coverage
Occupational therapy services:
In-network: $30 copay
Out-of-network: $40 copay
Physical therapy and speech and language therapy services:
In-network: $5 copay
Out-of-network: $5 copay
Urgent Care Coverage
$30 copay per visit (always covered)
Skilled Nursing Facility (SNF)
In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 100
Out-of-network: 30% per stay
Mental Health Coverage
Medicare-covered individual sessions: In-network: $40 copay
Out-of-network: $40 copay
Medicare-covered group sessions: In-network: $40 copay
Out-of-network: $40 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: In-network: $0 copay
Out-of-network: 30% coinsurance
Prophylaxis (cleaning): In-network: $0 copay
Out-of-network: 30% coinsurance
Dental x-rays: In-network: $0 copay
Out-of-network: 30% coinsurance
Vision Benefits
Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: $50 copay
Eyewear:
Contact Lenses: In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses: Not covered
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $10 copay
Out-of-network: $10 copay
Hearing aids:
Hearing aids (all types): In-network: $699-999 copay
Out-of-network: $0 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$126.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$7.00 copay (30-day supply)
$21.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$21.00 copay (90-day supply)
Tier 2: Generic
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$120.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$280.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
More Additional Benefits
Plan Links
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