Forever Blue Value (PPO)

4.5 out of 5 stars
$152.00
Monthly Premium

Forever Blue Value (PPO) is a PPO plan offered by Highmark Health

Plan ID: H5526-016

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 Value (PPO) - H5526-016 by Highmark Health as well as other Medicare Advantage plans available in your area.

$152.00
Monthly Premium

New York Counties Served

AlleganyBergenCattaraugusChautauquaErieGeneseeNiagaraOrleansWyoming

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 $10
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

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit $35%
Inpatient Hospital Care

Out-of-Network:

Acute Hospital Services:
Coinsurance for Acute Hospital Services per Stay 35%
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 $320
Ambulance Transportation

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $320
Copayment for Medicare Covered Ambulance Services - Air $320

Health Care Services and Medical Supplies

Forever Blue Value (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
  • Maximum 12 Routine Care every year

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 35%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring


Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 50%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%
Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to Abbott and Trividia. Continuous glucose monitors, sensors and transmitters dispensed via retail or mail order pharmacy are limited to Abbott and Dexcom. All other desired brands will need to be obtained via an exception process or from a Durable Medical Equipment (DME) supplier.
Durable Medical Equipment (DME)
In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
0% coinsurance for compression stockings, 20% for all other DME items
Diagnostic Tests, Lab and Radiology Services, and X-Rays

Out-of-Network:

Diagnostic Procedures/Tests Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
35%
Coinsurance for Medicare Covered Lab Services
35%
Coinsurance for Medicare Covered Diagnostic Radiological Services 35%
Coinsurance for Medicare Covered Therapeutic Radiological Services 35%
Coinsurance for Medicare Covered Outpatient X-Ray Services 35%
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

Out-of-Network:

Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $350
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $350

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient Substance Abuse Care

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%
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
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $40.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $40 every three months
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 35%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30
Copayment for Routine Foot Care $30
  • Maximum 3 visits every year
Skilled Nursing Facility Care

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 35%

Dental Benefits

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

Coverage Cost
Dental Care

In-Network:

Medicare Covered Dental:
Copayment for Office Visit $30

Non-Medicare Covered Preventive Dental:

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


Non-Medicare Covered Comprehensive Dental:

Coinsurance for Restorative services 50%

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


Out-of-Network:

Eye Exams Services:
Coinsurance for Medicare Covered Eye Exams 35%
Coinsurance for Medicare Covered Eyewear 20%

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 $30
Copayment for Routine Hearing Exams $45
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Each hearing aid purchase includes one year of follow-up provider visits for fitting and adjustments. These visits are available for 12 months following hearing aid purchase and only with the purchase of a hearing aid.

Hearing Aids:
Copayment for Hearing Aids $499 to $799
  • Maximum 2 Hearing Aids every year
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).

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

Prescription Drug Costs and Coverage

The Forever Blue Value (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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