Forever Blue 770 (PPO)
Forever Blue 770 (PPO) H5526-018 Plan Details
Forever Blue 770 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5526-018
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.
$198.00
Monthly Premium
Forever Blue 770 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5526-018
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.
New York Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6700 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 to $5 The maximum copay will apply for any Primary Care Physician visit, however, there is a $0 copay for follow up visits after any inpatient discharge or observation discharge within 14 days. Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 25% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $22 Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 25% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $205 per day for days 1 to 7 $0 per day for days 8 to 90 Maximum out of Pocket $1,435 every year Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 30% |
| Urgent Care | Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $55 |
| Emergency Room Visit | Copayment for Emergency Care $125 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $300 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300 Prior authorization required for air/water ambulance. Air Ambulance: Copayment for Air Ambulance Services $300 Prior Authorization Required for Air Ambulance Prior authorization required for air/water ambulance. Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $300 Copayment for Medicare Covered Ambulance Services - Air $300 Prior authorization required for air/water ambulance. |
Health Care Services and Medical Supplies
Forever Blue 770 (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
Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 25% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to LifeScan and Roche. 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 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50% Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to LifeScan and Roche. 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 0% to 20% Prior Authorization Required for Durable Medical Equipment 0% coinsurance for compression stockings, 20% for all other DME items Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% 0% coinsurance for compression stockings, 20% for all other DME items |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $40 Copayment for Medicare-covered Lab Services $5 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $150 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $40 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 25% Copayment for Medicare Covered Lab Services $5 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: 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 25% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $270 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 30% |
| 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: 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 $275 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $275 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $175 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 25% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 25% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Over-the-counter (OTC) Items | In-Network and Out-of-Network: 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 | In-Network: Copayment for Medicare-Covered Podiatry Services $22 Copayment for Routine Foot Care $22
Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 25% Non-Medicare Covered Podiatry Services: Coinsurance 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 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 $22 Non-Medicare Covered Preventive Dental: Copayment for Oral exams $0
Non-Medicare Covered Comprehensive Dental: Coinsurance for Restorative services 50%
Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Dental 25% Non-Medicare Covered Preventive Dental: Non-Medicare Covered Comprehensive Dental: |
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 to $22 Copayment for Routine Eye Exams $25
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $200 every year We are offering a supplemental benefit to members which provides a $200 vision allowance to use towards glasses/frames/lenses/contacts. Out-of-Network: Eye Exams : Coinsurance for Medicare Covered Eye Exams 25% Coinsurance for Routine 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 $22 Copayment for Routine Hearing Exams $45
Each hearing aid purchase includes one year of follow-up provider visits for fitting and adjustments. These visits are available for 12 months following hearing aid purchase and only with the purchase of a hearing aid. Hearing Aids: Copayment for Hearing Aids $499 to $799
Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance 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: Coinsurance for Medicare Covered Medicare-covered Preventive Services 30% |
