Highmark Blue Cross Blue Shield Forever Blue Value (PPO)

Highmark Blue Cross Blue Shield Forever Blue Value (PPO) H5526-016 Plan Details
5 out of 5 stars

Highmark Blue Cross Blue Shield Forever Blue Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Healthnow New York Inc..
Plan ID: H5526-016.

$146.00
Monthly Premium

Highmark Blue Cross Blue Shield Forever Blue Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Healthnow New York Inc..
Plan ID: H5526-016.

Highmark Blue Cross Blue Shield Forever Blue Value (PPO) H5526-016 Plan Details
5 out of 5 stars

Highmark Blue Cross Blue Shield Forever Blue Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Healthnow New York Inc..
Plan ID: H5526-016.

$146.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $6700
Out-of-Network: 10000
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00 to $10.00
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 35%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30.00
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 35%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$250.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Maximum out of Pocket $1750.00 every year
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 35%
Urgent Care
Copayment for Urgent Care $65.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $65.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Copayment for Air Ambulance Services $250.00

Prior authorization required for air/water ambulance.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Copayment for Medicare Covered Ambulance Services - Air $250.00

Health Care Services and Medical Supplies

Highmark Blue Cross Blue Shield 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:
Copayment for Medicare-covered Chiropractic Services $20.00
Copayment for Routine Care $20.00
  • Maximum 12 Routine Care every year

Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 35% Coinsurance for Non-Medicare Covered Chiropractic Services 35%
  • Maximum 12 Routine Care every year
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $45.00
Copayment for Medicare-covered Lab Services $5.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $150.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $45.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab 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:
Copayment for Medicare-covered Home Health Services $0.00
Out-of-Network:
Coinsurance for Medicare Covered Home Health 35%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$270.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Maximum out of Pocket $1620.00 every year
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 35%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Out-of-Network:
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 $350.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $200.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 35%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 35%
Outpatient Substance Abuse Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 50%
Coinsurance for Medicare-covered Group Sessions 50%
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 50%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $35.00 every three months
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $35.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $30.00
Copayment for Routine Foot Care $30.00
  • Maximum 3 visits every year
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 35% Coinsurance for Non-Medicare Covered Podiatry Services 35%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 35%

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $10.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $10.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $10.00
  • Maximum 1 visit every year

Comprehensive Dental:
Copayment for Medicare-covered Benefits $30.00
Copayment for Periodontics $10.00
  • Maximum 2 visits every year
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 35%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $10.00
Copayment for Non-Medicare Covered Comprehensive Dental $10.00

Vision Benefits

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

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $30.00
Copayment for Routine Eye Exams $25.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 35%
Coinsurance for Medicare Covered Eyewear 20%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 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 $30.00
Copayment for Routine Hearing Exams $45.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $599.00 to $899.00
  • Maximum 2 Hearing Aids every year
Copayment Structure
The $599 copay is for Truhearing's Advanced Hearing Aid and the $899 copay is for Truhearing's Premium Hearing Aid.
Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearings Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options for an additional $50 per aid. You must see a TruHearing provider to use this benefit.

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 models


Benefit 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

Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 35%
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $45.00
Copayment for Non-Medicare Covered Hearing Aids $599.00 to $899.00

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
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 shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit


Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 35%