2022 Highmark Blue Cross Blue Shield Forever Blue 751 (PPO)

Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) H5526-004 is a 2022 Medicare Advantage Plan or Part-C by Highmark Blue Cross Blue Shield of Western New Yo available to residents in New York. This plan includes additional prescription drug (Part-D) coverage. The Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) has a monthly premium of $205.00 and has an in-network maximum out-of-pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out-of-pocket. This can be a extremely nice safety net.

Highmark Blue Cross Blue Shield Forever Blue 751 (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 Blue Cross Blue Shield of Western New Yo works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Highmark Blue Cross Blue Shield of Western New Yo 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 Blue Cross Blue Shield of Western New Yo 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 Blue Cross Blue Shield of Western New Yo Medicare Advantage Plan Costs

Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) Part-C Premium

Highmark Blue Cross Blue Shield of Western New Yo charges a $132.50 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.

H5526-004 Part-D Deductible and Premium

Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) has a monthly drug premium of $32.00 and a $0.00 drug deductible. This Highmark Blue Cross Blue Shield of Western New Yo plan offers a $32.00 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 $40.50 this Premium covers any enhanced plan benefits offered by Highmark Blue Cross Blue Shield of Western New Yo 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 $72.50 . 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 Blue Cross Blue Shield of Western New Yo 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 Blue Cross Blue Shield of Western New Yo plan does not offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) medicare insurance offers a $40.50 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $48.50 for 75% low income subsidy $56.50 for 50% and $64.50 for 25%.

H5526-004 Formulary or Drug Coverage

Highmark Blue Cross Blue Shield Forever Blue 751 (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 Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) H5526-004 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$2	$7
Tier 2	$8	$13
Tier 3	$42	$47
Tier 4	$94	$99
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	$10 copay (Out-of-Network)
Periodontics	$10 copay
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$150 copay
Diagnostic radiology services (e.g., MRI)	25% coinsurance (Out-of-Network)
Diagnostic tests and procedures	25% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$40 copay
Lab services	$5 copay
Lab services	25% coinsurance (Out-of-Network)
Outpatient x-rays	$40 copay
Outpatient x-rays	25% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0-5 copay per visit
Primary	25% coinsurance per visit (Out-of-Network)
Specialist	25% coinsurance per visit (Out-of-Network)
Specialist	$25 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$65 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	25% coinsurance (Out-of-Network)
Foot exams and treatment	$25 copay
Routine foot care	25% coinsurance (Out-of-Network)
Routine foot care	$25 copay

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Ground Ambulance

$225 copay
$225 copay (Out-of-Network)

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Hearing

Fitting/evaluation	Not covered
Hearing aids	$699-999 copay (Out-of-Network)
Hearing aids	$699-999 copay
Hearing exam	25% coinsurance (Out-of-Network)
Hearing exam	$25 copay

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Inpatient Hospital Coverage

$205 per day for days 1 through 7 $0 per day for days 8 through 90
30% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	25% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	25% coinsurance (Out-of-Network)
Other Part B drugs	$25 copay or 20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	30% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$270 per day for days 1 through 6 $0 per day for days 7 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)

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MOOP

$10,000 In and Out-of-network $6,700 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

25% coinsurance per visit (Out-of-Network)
$300 copay per visit

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Package #1

Deductible
Monthly Premium	$11.00

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Package #2

Deductible
Monthly Premium	$25.00

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Preventive Care

25% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	$10 copay (Out-of-Network)
Cleaning	$10 copay
Dental x-ray(s)	$10 copay
Dental x-ray(s)	$10 copay (Out-of-Network)
Fluoride treatment	Not covered
Oral exam	$10 copay
Oral exam	$10 copay (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	25% coinsurance (Out-of-Network)
Occupational therapy visit	$20 copay
Physical therapy and speech and language therapy visit	25% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$20 copay

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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

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Transportation

Not covered

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	20% coinsurance (Out-of-Network)
Routine eye exam	$25 copay
Upgrades	$0 copay
Upgrades	$0 copay (Out-of-Network)

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) H5526

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) Plans Performance

Health Plan Customer Service Rating for Highmark Blue Cross Blue Shield Forever Blue 751 (PPO)

Highmark Blue Cross Blue Shield Forever Blue 751 (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

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

Coverage Area for Highmark Blue Cross Blue Shield Forever Blue 751 (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.