Complete Blue Plus PPO Merit (PPO)

4.5 out of 5 stars

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Monthly Premium

Complete Blue Plus PPO Merit (PPO) is a PPO plan offered by Highmark Health

Plan ID: H3916-064

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as Complete Blue Plus PPO Merit (PPO) - H3916-064 by Highmark Health as well as other Medicare Advantage plans available in your area.

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Monthly Premium

Pennsylvania Counties Served

Clinton Lycoming Sullivan

Basic Costs and Coverage

Coverage	Cost
Monthly Deductible	$615
Out of Pocket Max	In-Network: $8300 Out-of-Network: 8950
Initial Coverage Limit	$0
Catastrophic Coverage Limit	$2100
Primary Care Doctor Visit	Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit $40%
Specialty Doctor Visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40
Inpatient Hospital Care	Out-of-Network: Acute Hospital Services: $600 per day for days 1 to 5 $0 per day for days 6 to 90 Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care.
Urgent Care	Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40
Emergency Room Visit	Emergency Care: Copayment for Emergency Care $115 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $115 Copayment for Worldwide Emergency Transportation $320
Ambulance Transportation	Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $320 Coinsurance for Medicare Covered Ambulance Services - Ground $30% Copayment for Medicare Covered Ambulance Services - Air $320 Coinsurance for Medicare Covered Ambulance Services - Air $30% Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip.

Health Care Services and Medical Supplies

Complete Blue Plus PPO Merit (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage	Cost
Chiropractic Services	Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15 Maximum 4 Routine Care every year Prior Authorization Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring	In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Glucometers, test strips, lancets, control solution, replacement batteries, platforms, lens shield, and non-invasive vagus nerve stimulator are supplied at the minimum coinsurance. All other Medicare covered Diabetic Supplies at the maximum coinsurance.
Durable Medical Equipment (DME)	Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 40%
Diagnostic Tests, Lab and Radiology Services, and X-Rays	Out-of-Network: Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% The minimum copayment applies for Medicare-covered diagnostic procedures/tests and lab services provided at free standing labs. The maximum copayment applies for Medicare-covered diagnostic procedures/tests and lab services at all other places of service.
Home Health Care	Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care	Out-of-Network: Psychiatric Hospital Services: $475 per day for days 1 to 5 $0 per day for days 6 to 90 Private accommodations will be covered when medically necessary. Inpatient substance abuse is subject to the same cost sharing as Inpatient Psychiatric Hospital.
Mental Health Outpatient Care	Out-of-Network: Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40%
Outpatient Services / Surgery	Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $475 Copayment for Medicare Covered Ambulatory Surgical Center Services $475 Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment.
Outpatient Substance Abuse Care	Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45
Over-the-counter (OTC) Items
Podiatry Services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 Copayment for Routine Foot Care $40 Maximum 4 visits every year Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40%
Skilled Nursing Facility Care	In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Private accommodations will be covered when medically necessary.

Dental Benefits

The following dental services are covered from in-network providers.

Coverage	Cost
Dental Care	In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $40 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Maximum plan benefit of $1500.00 every year for Non-medicare preventive Copayment for Oral exams $0 Maximum 2 visits every year Copayment for Dental x-rays $0 Maximum 1 visit every year Copayment for Prophylaxis $0 Maximum 2 visits every year Copayment for Fluoride treatment $0 Maximum 2 visits every year Maximum Plan Benefit of $1,500 every year Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Coinsurance for Restorative services 50% Maximum 1 visit every two years Coinsurance for Endodontics 50% Maximum 1 visit (Please see Evidence of Coverage for details) Coinsurance for Periodontics 50% Maximum 2 visits (Please see Evidence of Coverage for details) Coinsurance for Prothodontics, removable 50% Maximum 1 visit (Please see Evidence of Coverage for details) Coinsurance for Prothodontics, fixed 50% Maximum 1 visit (Please see Evidence of Coverage for details) Coinsurance for Maxillofacial surgery 50% Maximum 1 visit (Please see Evidence of Coverage for details) Coinsurance for Adjunctive general services 0% to 50% Maximum 2 visits every year

Coverage

Cost

Dental Care

In-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $40

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0

Maximum plan benefit of $1500.00 every year for Non-medicare preventive

Copayment for Oral exams $0

Maximum 2 visits every year

Copayment for Dental x-rays $0

Maximum 1 visit every year

Copayment for Prophylaxis $0

Maximum 2 visits every year

Copayment for Fluoride treatment $0

Maximum 2 visits every year

Maximum Plan Benefit of $1,500 every year

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Coinsurance for Restorative services 50%

Maximum 1 visit every two years

Coinsurance for Endodontics 50%

Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Periodontics 50%

Maximum 2 visits (Please see Evidence of Coverage for details)

Coinsurance for Prothodontics, removable 50%

Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Prothodontics, fixed 50%

Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Maxillofacial surgery 50%

Maximum 1 visit (Please see Evidence of Coverage for details)

Coinsurance for Adjunctive general services 0% to 50%

Maximum 2 visits every year

Vision Benefits

The following vision services are covered from in-network providers.

Coverage	Cost
Vision Benefits	Out-of-Network: Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Copayment for Medicare Covered Eyewear $0

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage	Cost
Hearing Benefits	Out-of-Network: Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 40%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage	Cost
Preventive Services and Health/Wellness Education Programs	In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots: COVID-19 shots Flu shots Hepatitis B shots Pneumococcal shots Tobacco use cessation Yearly "Wellness" visit

Coverage

Cost

Preventive Services and Health/Wellness Education Programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

COVID-19 shots
Flu shots
Hepatitis B shots
Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

Prescription Drug Costs and Coverage

The Complete Blue Plus PPO Merit (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $615 (excludes Tiers 1 and 2) per year.

Coverage	Cost
Coverage & Cost
Annual Drug Deductible	$615 (excludes Tiers 1 and 2)
Preferred Generic	Preferred cost-share mail order N/A Standard retail $7.00 Standard mail order N/A Preferred cost-share retail $0.00
Generic	Preferred cost-share mail order N/A Standard retail $15.00 Standard mail order N/A Preferred cost-share retail $0.00
Annual Drug Deductible	$615 (excludes Tiers 1 and 2)
Preferred Generic	Preferred cost-share mail order N/A Standard retail N/A Standard mail order N/A Preferred cost-share retail N/A
Generic	Preferred cost-share mail order N/A Standard retail N/A Standard mail order N/A Preferred cost-share retail N/A
Annual Drug Deductible	$615 (excludes Tiers 1 and 2)
Preferred Generic	Preferred cost-share mail order $0.00 Standard retail $21.00 Standard mail order $21.00 Preferred cost-share retail $0.00
Generic	Preferred cost-share mail order $0.00 Standard retail $45.00 Standard mail order $45.00 Preferred cost-share retail $0.00

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