Complete Blue PPO Distinct (PPO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Highmark Blue Cross Blue Shield
- Rx
- Vision
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: 40% coinsurance
Out-of-network: 40% coinsurance
Out-of-network: $0 copay
Emergency Room
$130 copay
Ambulance Coverage
In-network: $320 copay
Out-of-network: $320 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $10-$20 copay
Out-of-network: 40% coinsurance
Lab services:
In-network: $10-$20 copay
Out-of-network: 40% coinsurance
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $300 copay
Out-of-network: 40% coinsurance
Outpatient x-rays:
In-network: $10 copay
Out-of-network: 40% coinsurance
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$355 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
$425 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Outpatient hospital coverage:
In-network: $350 copay
Out-of-network: $425 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $35 copay
Out-of-network: 40% coinsurance
Urgent Care Coverage
$130 copay
Skilled Nursing Facility (SNF)
In-network:
Tier 1
$0 per day for days 1-20
$218 per day for days 21-100
Out-of-network:
30% per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $30 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy with a psychiatrist:
In-network: $30 copay
Out-of-network: 40% coinsurance
Outpatient group therapy visits:
In-network: $30 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy visit:
In-network: $30 copay
Out-of-network: 40% coinsurance
Dental, Vision, Hearing Benefits
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $50 copay
Additional Added Benefits
Plan Links
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