Complete Blue PPO Signature (PPO)

4 out of 5 stars
$0.00
Monthly Premium

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

Plan ID: H8166-005

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 PPO Signature (PPO) - H8166-005 by Highmark Health as well as other Medicare Advantage plans available in your area.

$0.00
Monthly Premium

Delaware Counties Served

New Castle

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $615
Out of Pocket Max In-Network: $6750
Out-of-Network: 10000
Initial Coverage Limit $0
Catastrophic Coverage Limit $2100
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $50
Inpatient Hospital Care

Out-of-Network:

Acute Hospital Services:
$390 per day for days 1 to 7
$0 per day for days 8 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 $50

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50
Emergency Room Visit

Emergency Care:
Copayment for Emergency Care $130

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $130
Copayment for Worldwide Emergency Transportation $505
Ambulance Transportation

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $505
Coinsurance for Medicare Covered Ambulance Services - Ground $30%
Copayment for Medicare Covered Ambulance Services - Air $505
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 PPO Signature (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 8 Routine Care every year
Prior Authorization Required for Chiropractic Services
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Copayment for Routine Care $15
  • Maximum 8 Routine Care every year
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 40%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring

Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 40%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40%
Durable Medical Equipment (DME)
In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 50%
Prior Authorization Required for Durable Medical Equipment
The minimum coinsurance applies to compression stockings and the maximum coinsurance applies to Oxygen, Ventilators, Wheelchairs and Wheelchair Accessories, all other DME items will have an intermediate coinsurance applied.
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $10
Copayment for Medicare-covered Lab Services $0 to $10
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
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.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $350
Copayment for Medicare-covered Therapeutic Radiological Services $60
Copayment for Medicare-covered X-Ray Services $25
Home Health Care
In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental Health Inpatient Care

Out-of-Network:

Psychiatric Hospital Services:
$500 per day for days 1 to 3
$0 per day for days 4 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 $450
Copayment for Medicare Covered Ambulatory Surgical Center Services $400
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
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%

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 $40
Copayment for Medicare-covered Group Sessions $40
Over-the-counter (OTC) Items

Out-of-Network:

Over-The-Counter (OTC) Items Services:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0
Maximum Plan Benefit of $25
An OTC catalog of CMS-approved non-prescription over-the-counter medications and health-related items is available. Quantity limits and plan restrictions may apply.
Podiatry Services

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 40%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $50
Copayment for Routine Foot Care $50
  • Maximum 10 visits every year
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $50
Copayment for Routine Foot Care $50
  • Maximum 10 visits every year

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 40%
Skilled Nursing Facility Care

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 30%
Private accommodations will be covered when medically necessary.

Dental Benefits

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

Coverage Cost
Dental Care


Out-of-Network:

Dental Services:
Coinsurance for Medicare Covered Dental 40%

Preventive Dental Services:

Coinsurance for Covered Routine Dental 30%

Comprehensive Dental Services:

Coinsurance for Covered Comprehensive Dental services 50%

Please see Evidence of Coverage for details

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%

Hearing Benefits

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

Coverage Cost
Hearing Benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $50
Copayment for Routine Hearing Exams $30

  • Maximum 1 visit every year


Hearing Aids:
Copayment for Hearing Aids $699 to $999

  • Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $500 every year for any other hearing aid.
Members must use our contracted provider to use this benefit. Up to two hearing aids every year (one per ear per year). Benefit is limited to the Advanced (minimum cost sharing) and Premium (maximum cost sharing) hearing aids, which come in various styles and colors, and are available in rechargeable style options at no additional charge.Hearing aid purchase includes:- First year of follow-up provider visits- 60-day trial period- 3-year extended warranty- 80 batteries per aid for non-rechargeable modelsBenefit does not include or cover any of the following:• Additional cost for optional hearing aid rechargeability • Ear molds• Hearing aid accessories• Additional provider visits• Additional batteries - batteries when a rechargeable hearing aid is purchased• Hearing aids that are not TruHearing-branded hearing aids• Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan.Services not covered under any condition:Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), ear molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the 80 free batteries per non-rechargeable aid purchased).Members have a $500 maximum allowance towards hearing aids that are not the Advanced or Premium models.

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

Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0

Prescription Drug Costs and Coverage

The Complete Blue PPO Signature (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 $3.00
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 $7.00
  • Standard retail $45.00
  • Standard mail order $45.00
  • Preferred cost-share retail $9.00
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