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Forever Blue 770 (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$220.00
Monthly Premium
Forever Blue 770 (PPO) is a PPO plan offered by Highmark Health
Plan ID: H5526-018
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 Forever Blue 770 (PPO) - H5526-018 by Highmark Health as well as other Medicare Advantage plans available in your area.
$220.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $615 |
| Out of Pocket Max |
In-Network: $6700 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 to $5 The maximum copay will apply for any Primary Care Physician visit, however, there is a $0 copay for follow up visits after any inpatient discharge or observation discharge within$ 14 days. |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $22 |
| Inpatient Hospital Care | Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 30% |
| 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 $315 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Air Ambulance: Copayment for Air Ambulance Services $315 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Forever Blue 770 (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 | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 25% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: |
| Durable Medical Equipment (DME) |
|
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Out-of-Network: Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 25% Copayment for Medicare Covered Lab Services $5 Coinsurance for Medicare Covered Diagnostic Radiological Services 25% Coinsurance for Medicare Covered Therapeutic Radiological Services 25% Coinsurance for Medicare Covered Outpatient X-Ray Services 25% |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $270 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $275 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $175 Prior Authorization Required for Ambulatory Surgical Center Services |
| 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 50% Coinsurance for Medicare Covered Group Sessions 50% |
| 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 $40 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 25% In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $22 Copayment for Routine Foot Care $22
|
| Skilled Nursing Facility Care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 30% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network:
Copayment for Dental x-rays $0
Copayment for Prophylaxis $0
Coinsurance for Endodontics 50% Coinsurance for Periodontics 0% to 50% Coinsurance for Prothodontics, removable 50% Coinsurance for Prothodontics, fixed 50% Coinsurance for Maxillofacial surgery 50% Coinsurance for Adjunctive general services 50% Maximum Plan Benefit of $2,000 every year Please see Evidence of Coverage for details |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits |
|
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits |
|
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: Coinsurance for Medicare Covered Medicare-covered Preventive Services 30% |
Prescription Drug Costs and Coverage
The Forever Blue 770 (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 |
|
| Generic |
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|