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Complete Blue PPO Merit (PPO) - H3916-049-002

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Complete Blue PPO Merit (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health

Plan ID: H3916-049-002

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Pennsylvania 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 Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$550.00
Out-of-pocket maximum$7,950.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $50
Inpatient hospital care
Out-of-Network:

Acute Hospital Services:
$600 per day for days 1 to 3
$0 per day for days 4 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 $45

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $45
Emergency room visit
Emergency Care:
Copayment for Emergency Care $110

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $110
Copayment for Worldwide Emergency Transportation $375
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $375
Coinsurance for Medicare Covered Ambulance Services - Ground 30%
Copayment for Medicare Covered Ambulance Services - Air $375
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 Merit (PPO) covers a range of additional benefits. Learn more about Complete Blue PPO Merit (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Medicare Covered Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $35
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Glucometers, test strips, lancets, control solution, replacement batteries, platforms, lens shield, and non-invasive vagus nerve stimulator are supplied at a $0 copay. All other Medicare covered Diabetic Supplies have a 20% coinsurance.Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to Abbott and LifeScan. 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)
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

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

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $300
Copayment for Medicare-covered Therapeutic Radiological Services $60
Copayment for Medicare-covered X-Ray Services $20
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$400 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
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:

Medicare Covered Mental Health Services:
Copayment for Medicare Covered Individual Sessions $50
Copayment for Medicare Covered Group Sessions $50
Outpatient services/surgery
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $375
Copayment for Medicare Covered Ambulatory Surgical Center Services $375
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
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $50
Copayment for Medicare Covered Group Sessions $50
Over-the-counter itemsIn-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
An OTC catalog of CMS-approved non-prescription over-the-counter medications and health-related items is available. COVID-19 tests are included. Quantity limits and plan restrictions apply.
Podiatry services
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $50

Non-Medicare Covered Podiatry Services:
Copayment for Non-Medicare Covered Podiatry Services $50
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Private accommodations will be covered when medically necessary.

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network:

Medicare Covered Dental:
Copayment for Office Visit $40

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
  • Maximum plan benefit of $1500.00 every year for Non-medicare preventive
Copayment for Oral exams $0
  • Maximum 1 visit every six months
Copayment for Dental x-rays $0
  • Maximum 1 visit every year
Copayment for Prophylaxis $0
  • Maximum 1 visit every six months
Copayment for Flouride treatment $0
  • Maximum 1 visit every six months
Maximum Plan Benefit of $1,500 every year

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Coinsurance for Restorative services 50%
  • Maximum 1 visit every two years
Coinsurance for Endodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Periodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prothodontics, removable 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prothodontics, fixed 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Maxillofacial surgery 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Adjunctive general services 0% to 50%
  • Maximum 2 visits every year

Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Dental $50

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $40
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Maximum Plan Allowance of $400 every year
A $200 benefit maximum applies to upgrades to post cataract surgery eyewear that are not medically necessary. Benefit maximum is available following cataract surgery once per operated eye. For non-post cataract eyewear, the Plan offers additional coverage for non-Medicare covered (routine) eyewear. Routine eyewear benefit is limited to one pair of eyeglass frames, including one pair of eyeglass lenses or contact lenses every calendar year. Standard eyeglass frames, standard plastic eyeglass lenses, or standard contact lenses are covered in full at participating network provider locations. A $200 benefit maximum is available towards the purchase of non-standard eyeglass frames or towards the purchase of non-standard contact lenses. Members must pay the difference between benefit maximums and provider charge.

Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $50
Copayment for Routine Eye Exams $50

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing care
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $50

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-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 Complete Blue PPO Merit (PPO) offers prescription drug coverage, with an annual drug deductible of $550.00 (excludes Tiers 1 and 2)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$550.00 (excludes Tiers 1 and 2)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $7.00
    • Preferred mail order N/A
    • Standard mail order N/A
    Tier 2
    • Preferred retail $0.00
    • Standard retail $15.00
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual drug deductible$550.00 (excludes Tiers 1 and 2)
    Tier 1
    • Preferred retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Tier 2
    • Preferred retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual drug deductible$550.00 (excludes Tiers 1 and 2)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $21.00
    • Preferred mail order $0.00
    • Standard mail order $21.00
    Tier 2
    • Preferred retail $0.00
    • Standard retail $45.00
    • Preferred mail order $0.00
    • Standard mail order $45.00

    When reviewing Pennsylvania 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 Pennsylvania 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.

    Plan Documents

    Links to plan documents

    Pennsylvania Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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