Community Blue Medicare PPO Signature (PPO)


Medicare Plan Details

2020 Plan
Monthly Premium
(select county for price)

 

by Highmark Inc.
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
 4.5
out of 5 stars

State: Pennsylvania

Select your county to view the price for this plan

 


Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$10,000 In and Out-of-network
$6,700 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

In-network: $0 copay
Out-of-network: $0 copay
In-network: $35 per visit
Out-of-network: $35 per visit

Tests, labs, & imaging

In-network: $0-30
Out-of-network: $40
In-network: $0-30
Out-of-network: $40
In-network: $270
Out-of-network: $370
In-network: $40
Out-of-network: $60
$90 per visit (always covered)
$50 per visit (always covered)

Hospital Services

In-network: $395 per stay
Out-of-network: $225 per day for days 1 through 7
$0 per day for days 8 through 90
In-network: $325 per visit
Out-of-network: $425 per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$178 per day for days 21 through 100
Out-of-network: 30% per stay

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $295
Out-of-network: $295 or 30%

Therapy services

In-network: $40
Out-of-network: $60
In-network: $40
Out-of-network: $60

Mental health services

In-network: $40
Out-of-network: $60
In-network: $40
Out-of-network: $60
In-network: $40
Out-of-network: $60
In-network: $40
Out-of-network: $60

Opioid treatment services

Covered

Other services

In-network: 20% per item
Out-of-network: 30% per item
In-network: 20% per item
Out-of-network: 30% per item
In-network: 0-20% per item
Out-of-network: 30% per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$7.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$3.60 copay or 5% (whichever costs more)

Brand-name drugs :
$8.95 copay or 5% (whichever costs more)

Generic$15.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier33%

Part B Drugs

In-network: 20%
Out-of-network: 30%
In-network: 20%
Out-of-network: 30%

Extra Benefits

Hearing

In-network: $35
Out-of-network: $35
Not covered
In-network: $699-999
Out-of-network: $0 copay

Preventive Dental

Covered under office visit
Covered under office visit
Not covered
In-network: $15
Out-of-network: 30%

Comprehensive dental

Not covered
Not covered
In-network: 50%
Out-of-network: 50%
Not covered
Not covered
In-network: 50%
Out-of-network: 50%
In-network: 50%
Out-of-network: 50%

Vision

In-network: $0 copay
Out-of-network: $50
In-network: $0 copay
Out-of-network: $0 copay
Not covered
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Other benefits

Limited coverage
Limited coverage
Not covered
Limited coverage
Not covered
Limited coverage
Limited coverage
 4.5
 4
 4
 4
 4
 5
 4.5
 4
 4
 5
 4

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