2022 Complete Blue PPO Signature (PPO)


Complete Blue PPO Signature (PPO) H3916-038 is a 2022 Medicare Advantage Plan or Part-C by Highmark Inc available to residents in Pennsylvania. This plan includes additional prescription drug (Part-D) coverage. The Complete Blue PPO Signature (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,500 out-of-pocket. This can be a extremely nice safety net.

Complete Blue PPO Signature (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Highmark Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Complete Blue PPO Signature (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Highmark Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Highmark Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Highmark Inc Medicare Advantage Plan Costs

Name:
Complete Blue PPO Signature (PPO)
Plan ID:
H3916-038
Provider:Highmark Inc
Year:2022
Type: Local PPO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $6,500
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:No
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H3916-039
New Plan: 2023 H3916-039




Complete Blue PPO Signature (PPO) Part-C Premium

Highmark Inc charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



H3916-038 Part-D Deductible and Premium

Complete Blue PPO Signature (PPO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Highmark Inc plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Highmark Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.



Highmark Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Highmark Inc plan does not offer additional coverage through the gap.



H3916-038 Formulary or Drug Coverage

Complete Blue PPO Signature (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Complete Blue PPO Signature (PPO) H3916-038 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $7
Tier 2 $5 $15
Tier 3 $47 $47
Tier 4 $100 $100
Tier 5 33% 33%
*Initial Coverage Phase and 30 day supply





2021 Complete Blue PPO Signature (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services Not covered
Endodontics 50% coinsurance
Endodontics 50% coinsurance (Out-of-Network)
Extractions 50% coinsurance
Extractions 50% coinsurance (Out-of-Network)
Non-routine services Not covered
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services 50% coinsurance (Out-of-Network)
Restorative services 50% coinsurance
Restorative services 50% coinsurance (Out-of-Network)



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $250 copay
Diagnostic radiology services (e.g., MRI) $350 copay (Out-of-Network)
Diagnostic tests and procedures $0-25 copay
Diagnostic tests and procedures $35 copay (Out-of-Network)
Lab services $35 copay (Out-of-Network)
Lab services $0-25 copay
Outpatient x-rays $20 copay
Outpatient x-rays $35 copay (Out-of-Network)



Doctor Visits


Primary $0 copay (Out-of-Network)
Primary $0 copay
Specialist $30 copay per visit
Specialist $30 copay per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $50 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $30 copay (Out-of-Network)
Foot exams and treatment $30 copay
Routine foot care $30 copay (Out-of-Network)
Routine foot care $30 copay



Ground Ambulance


$275 copay
$275 copay or 30% coinsurance (Out-of-Network)



Hearing


Fitting/evaluation Not covered
Hearing aids $0 copay (Out-of-Network)
Hearing aids $699-999 copay
Hearing exam $30 copay
Hearing exam $30 copay (Out-of-Network)



Inpatient Hospital Coverage


$325 per stay
$475 per stay (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies 30% coinsurance per item (Out-of-Network)
Diabetes supplies 0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) 30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 30% coinsurance per item (Out-of-Network)



Medicare Part B Drugs


Chemotherapy 30% coinsurance (Out-of-Network)
Chemotherapy 20% coinsurance
Other Part B drugs 30% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $425 per day for days 1 through 3
$0 per day for days 4 through 90
Inpatient hospital - psychiatric $500 per day for days 1 through 3
$0 per day for days 4 through 90 (Out-of-Network)
Outpatient group therapy visit $60 copay (Out-of-Network)
Outpatient group therapy visit $40 copay
Outpatient group therapy visit with a psychiatrist $40 copay
Outpatient group therapy visit with a psychiatrist $60 copay (Out-of-Network)
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit $60 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit with a psychiatrist $60 copay (Out-of-Network)



MOOP


$10,000 In and Out-of-network
$6,500 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$350 copay per visit (Out-of-Network)
$250 copay per visit



Preventive Care


$0 copay (Out-of-Network)
$0 copay



Preventive Dental


Cleaning Covered under office visit
Dental x-ray(s) $15 copay
Dental x-ray(s) 30% coinsurance (Out-of-Network)
Fluoride treatment Not covered
Office visit $15.00
Office visit 30% coinsurance (Out-of-Network)
Oral exam Covered under office visit



Rehabilitation Services


Occupational therapy visit $60 copay (Out-of-Network)
Occupational therapy visit $40 copay
Physical therapy and speech and language therapy visit $50 copay (Out-of-Network)
Physical therapy and speech and language therapy visit $30 copay



Skilled Nursing Facility


30% per stay (Out-of-Network)
$0 per day for days 1 through 20
$184 per day for days 21 through 100



Transportation


$0 copay
30% coinsurance (Out-of-Network)



Vision


Contact lenses $0 copay
Contact lenses $0 copay (Out-of-Network)
Eyeglass frames $0 copay (Out-of-Network)
Eyeglass frames $0 copay
Eyeglass lenses $0 copay
Eyeglass lenses $0 copay (Out-of-Network)
Eyeglasses (frames and lenses) Not covered
Other Not covered
Routine eye exam $50 copay (Out-of-Network)
Routine eye exam $0 copay
Upgrades $0 copay
Upgrades $0 copay (Out-of-Network)



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Complete Blue PPO Signature (PPO) H3916



2021 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Complete Blue PPO Signature (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Complete Blue PPO Signature (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Complete Blue PPO Signature (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST




Coverage Area for Complete Blue PPO Signature (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

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