Complete Blue PPO Signature (PPO)
Medicare Plan Details (2023 Plan)
Monthly Premium
by Highmark Inc.
Additional Coverage
Overall Government Star Rating
5.0Ready to Enroll Online?
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
Plan Details
$7,550 In-network
Medical Benefits
Doctor Services
Out-of-network: $0 copay
Out-of-network: $25 copay per visit
Tests, labs, & imaging
Out-of-network: $25 copay
Out-of-network: $25 copay
Out-of-network: $325 copay
Out-of-network: $35 copay
Hospital Services
$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
Out-of-network: $375 copay per visit
Skilled nursing facility
$196 per day for days 21 through 100
Out-of-network: 30% per stay
Preventive services
Out-of-network: $0 copay
Ambulance
Out-of-network: $275 copay or 30% coinsurance
Therapy services
Out-of-network: $50 copay
Out-of-network: $35 copay
Mental health services
Out-of-network: $50 copay
Out-of-network: $50 copay
Out-of-network: $50 copay
Out-of-network: $50 copay
Opioid treatment services
Other services
Out-of-network: 30% coinsurance per item
Out-of-network: 30% coinsurance per item
Out-of-network: 30% coinsurance per item
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Gap coverage phase | Catastrophic coverage phase |
|---|---|---|---|
| Preferred Generic | $7.00 copay |
Brand-name drugs :
|
Brand-name drugs :
|
| Generic | $15.00 copay | ||
| Preferred Brand | $47.00 copay | ||
| Non-Preferred Drug | $100.00 copay | ||
| Specialty Tier | 33% |
Part B Drugs
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Extra Benefits
Hearing
Out-of-network: $25 copay
Out-of-network: $0 copay
Preventive Dental
Out-of-network: 30% coinsurance
Comprehensive dental
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Vision
Out-of-network: $50 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Other benefits
Health Plan Star Ratings
(government star ratings are out of 5 stars)
Prescription Drug Plan Star Ratings
(government star ratings are out of 5 stars)
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