Complete Blue PPO Signature (PPO)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

by Highmark Inc.
Additional Coverage
HearingVisionDental
Overall Government Star Rating
 5.0
out of 5 stars

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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
$7,550 In-network
No
Yes
Yes
Yes

Doctor Services

In-network: $0 copay
Out-of-network: $0 copay
In-network: $25 copay per visit
Out-of-network: $25 copay per visit

Tests, labs, & imaging

In-network: $0 copay
Out-of-network: $25 copay
In-network: $0 copay
Out-of-network: $25 copay
In-network: $195 copay
Out-of-network: $325 copay
In-network: $20 copay
Out-of-network: $35 copay
$95 copay per visit (always covered)
$50 copay per visit (always covered)

Hospital Services

In-network: $150 per day for days 1 through 3
$0 per day for days 4 through 90
Out-of-network: $300 per day for days 1 through 3
$0 per day for days 4 through 90
In-network: $245 copay per visit
Out-of-network: $375 copay per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$196 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: $275 copay
Out-of-network: $275 copay or 30% coinsurance

Therapy services

In-network: $30 copay
Out-of-network: $50 copay
In-network: $20 copay
Out-of-network: $35 copay

Mental health services

In-network: $40 copay
Out-of-network: $50 copay
In-network: $40 copay
Out-of-network: $50 copay
In-network: $40 copay
Out-of-network: $50 copay
In-network: $40 copay
Out-of-network: $50 copay

Opioid treatment services

Covered

Other services

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

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 :
$4.15 copay or 5% (whichever costs more)

Brand-name drugs :
$10.35 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% coinsurance
Out-of-network: 30% coinsurance
In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Hearing

In-network: $25 copay
Out-of-network: $25 copay
Not covered
In-network: $699-999 copay
Out-of-network: $0 copay

Preventive Dental

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

Comprehensive dental

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

Vision

In-network: $0 copay
Out-of-network: $50 copay
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
 5
 4
 4
 5
 5
 5
 5
 5
 5
 5
 4

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