Senior Blue Basic (HMO)
Senior Blue Basic (HMO) H3384-067 Plan Details
Senior Blue Basic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3384-067
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.
$0.00
Monthly Premium
Senior Blue Basic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3384-067
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: $8300 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 $10 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. |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $50 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $375 per day for days 1 to 6 $0 per day for days 7 to 90 Maximum out of Pocket $2,250 every year Prior Authorization Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $45 |
| Emergency Room Visit | Copayment for Emergency Care $110 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110 Copayment for Worldwide Emergency Transportation $275 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275 Prior authorization required for air/water ambulance. Air Ambulance: Copayment for Air Ambulance Services $275 Prior Authorization Required for Air Ambulance Prior authorization required for air/water ambulance. Prior authorization required |
Health Care Services and Medical Supplies
Senior Blue Basic (HMO) 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
|
| 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. |
| 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 |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $60 Copayment for Medicare-covered Lab Services $10 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $225 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $50 Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $335 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 |
| Mental Health Outpatient Care | In-Network: 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 $475 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $475 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $425 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $50 Copayment for Routine Foot Care $50
|
| 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 $50 Non-Medicare Covered Preventive Dental:
Non-Medicare Covered Comprehensive Dental: Coinsurance for Restorative services 0% to 50%
|
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 $50 Copayment for Routine Eye Exams $25
|
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 $50 |
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 |
