Complete Blue PPO Choice Deluxe (PPO)
Complete Blue PPO Choice Deluxe (PPO) H3916-047 Plan Details
Complete Blue PPO Choice Deluxe (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-047
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.
$6.00
Monthly Premium
Complete Blue PPO Choice Deluxe (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-047
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.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6500 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $25 Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $25 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $325 Prior Authorization Required for Acute Hospital Services Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care. Prior authorization required Out-of-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $325 Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care. |
| Urgent Care | Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $50 |
| Emergency Room Visit | Copayment for Emergency Care $125 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $400 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $400 Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. Air Ambulance: Copayment for Air Ambulance Services $400 Prior Authorization Required for Air Ambulance Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $400 Coinsurance for Medicare Covered Ambulance Services - Ground 30% Copayment for Medicare Covered Ambulance Services - Air $400 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 Choice Deluxe (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 $15 Copayment for Routine Care $15
Prior authorization required Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: 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. Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 30% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 30% 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 Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required 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-Rays | In-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 $225 Copayment for Medicare-covered Therapeutic Radiological Services $75 Copayment for Medicare-covered X-Ray Services $20 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 Copayment for Medicare Covered Lab Services $0 Copayment for Medicare Covered Diagnostic Radiological Services $225 Copayment for Medicare Covered Therapeutic Radiological Services $75 Copayment for Medicare Covered Outpatient X-Ray Services $20 |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 30% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $425 per day for days 1 to 3 $0 per day for days 4 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. Prior authorization required Out-of-Network: Psychiatric Hospital Services: $475 per day for days 1 to 3 $0 per day for days 4 to 90 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 | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $40 Copayment for Medicare Covered Group Sessions $40 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300 Prior Authorization Required for Outpatient Hospital Services 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 Observation Services: Copayment for Medicare Covered Observation Services - Per day $300 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. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $200 Prior Authorization Required for Ambulatory Surgical Center Services 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. Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300 Copayment for Medicare Covered Ambulatory Surgical Center Services $200 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 | In-Network: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 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 (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0 The OTC benefit is part of a combined benefits/reduction in cost sharing package that includes dental/vision/hearing/OTC up to $425 maximum administered through a debit card. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $25 Copayment for Routine Foot Care $25
Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $25 Non-Medicare Covered Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $25 |
| Skilled Nursing Facility Care | In-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. Prior authorization required |
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 $25 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Coinsurance for Restorative services 50%
Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Dental $25 |
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 $25 Copayment for Routine Eye Exams $0
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 $25 Copayment for Routine Eye Exams $50 |
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 $25 Copayment for Routine Hearing Exams $10
Hearing Aids: Copayment for Hearing Aids $699 to $999
You must see a TruHearing provider to use this benefit. Up to two TruHearing branded hearing aids every year (one per ear per year). Benefit is limited to the TruHearing Advanced ($699) and Premium ($999) 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 u Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $25 |
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:
Yearly "Wellness" visit Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
