Forever Blue 770 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5526-018-000
New York Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about New York Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Coverage | Details |
---|---|
Monthly plan premium | $206.00 |
Vision coverage | |
Dental coverage | |
Hearing coverage | |
Prescription drugs | |
Medical deductible | $0.00 |
Out-of-pocket maximum | $6,700.00 |
Initial drug coverage limit | $0.00 |
Catastrophic drug coverage limit | $8,000.00 |
Primary care doctor visit | Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 25% |
Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $22.00 |
Inpatient hospital care | Out-of-Network: Coinsurance for Acute Hospital Services per Stay 30% |
Urgent care | Urgent Care: Copayment for Urgent Care $55.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $55.00 |
Emergency room visit | Emergency Care: Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 |
Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $200.00 Copayment for Medicare Covered Ambulance Services - Air $200.00 |
Forever Blue 770 (PPO) covers a range of additional benefits. Learn more about Forever Blue 770 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
Coverage | Details |
---|---|
Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 25% Chiropractic Services: Coinsurance for Non-Medicare Covered Chiropractic Services 25% |
Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: 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) |
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 |
Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 25% Copayment for Medicare Covered Lab Services $5.00 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 $0.00 |
Mental health inpatient care | Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 30% |
Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $275.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $175.00 Prior Authorization Required for Ambulatory Surgical Center Services |
Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
Over-the-counter items | 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: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $22.00 Copayment for Routine Foot Care $22.00
|
Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Dental care | In-Network: Preventive Dental: Copayment for Office Visit: $0 including: • Oral Exams Maximum 2 per year • Prophylaxis (Cleaning) Maximum 2 per year • Dental X-Rays Maximum 1 visit every year Medicare Covered Dental Services: Copayment for Medicare-covered Benefits $22.00
|
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Vision benefits | Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 25% Coinsurance for Medicare Covered Eyewear 20% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 20% Copayment for Non-Medicare Covered Eyewear $0.00 |
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Hearing benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $22.00 Copayment for Routine Hearing Exams $45.00
Hearing Aids: Copayment for Hearing Aids $499.00 to $799.00
|
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
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:
Yearly "Wellness" visit |
When reviewing New York Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of New York that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Links to plan documents |
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
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