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Forever Blue Value (PPO) - H5526-016-000

4 out of 5 stars* for plan year 2025

$131.00

Monthly Premium

Forever Blue Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health

Plan ID: H5526-016-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$131.00

Monthly Premium

New York Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about New York Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$131.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$6,700.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-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.

Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit 35%
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30
Inpatient hospital care
Out-of-Network:

Acute Hospital Services:
Coinsurance for Acute Hospital Services per Stay 35%
Urgent care
Urgent Care:
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $55
Emergency room visit
Emergency Care:
Copayment for Emergency Care $125

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Copayment for Worldwide Emergency Transportation $250
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250
Copayment for Medicare Covered Ambulance Services - Air $250
Prior authorization required for air/water ambulance.

Health Care Services and Medical Supplies

Forever Blue Value (PPO) covers a range of additional benefits. Learn more about Forever Blue Value (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Copayment for Routine Care $15
  • Maximum 12 Routine Care every year
Diabetes supplies, training, nutrition therapy and monitoring
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 equipment (DME)In-Network:

Durable Medical Equipment:
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
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $45
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 $45
Home health care
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 35%
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 35%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Outpatient services/surgery
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 35%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 35%
Outpatient substance abuse care
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 itemsIn-Network and Out-of-Network :

Over-The-Counter (OTC) Items:
  • Maximum plan benefit of $60.00 every three months for 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
Out-of-Network:

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 35%

Non-Medicare Covered Podiatry Services:
Coinsurance for Non-Medicare Covered Podiatry Services 35%
Skilled Nursing Facility (SNF) careIn-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

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network:

Medicare Covered Dental:
Copayment for Office Visit $30

Non-Medicare Covered Preventive Dental:
Copayment for Oral exams $0
  • Maximum 1 visit every six months
Copayment for Dental x-rays $0
  • Maximum 1 visit every year
Copayment for Prophylaxis $0
  • Maximum 1 visit every six months

Non-Medicare Covered Comprehensive Dental:
Coinsurance for Restorative services 50%
  • Maximum 1 visit every two years
Coinsurance for Endodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Periodontics 0% to 50%
  • Maximum 1 visit every six months (Please see Evidence of Coverage for details)
Coinsurance for Prothodontics, removable 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prothodontics, fixed 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Maxillofacial surgery 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Adjunctive general services 50%
  • Maximum 2 visits every year
Maximum Plan Benefit of $2,000 every year for comprehensive services

Out-of-Network:

Medicare Covered Preventive Dental Services:
Coinsurance for Medicare Covered Preventive Dental 35%

Non-Medicare Covered Preventive Dental:
Coinsurance for covered Preventive Dental: 0%

Non-Medicare Covered Comprehensive Dental:
Coinsurance for covered Comprehensive Dental: 50%

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $30
Copayment for Routine Eye Exams $25
  • Maximum 1 Routine Eye Exam every year

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: 35%
Coinsurance for Routine Eye Exams: 20%
Eyewear:
Coinsurance for Medicare Covered Eyewear: 20%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30
Copayment for Routine Hearing Exams $45
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
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
  • Maximum 2 Hearing Aids every year
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 ($499) and Premium ($799) 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 models Benefit 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 war

Out-of-Network:

Medicare Covered Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 35%

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 35%

When reviewing New York Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of New York that offer similar benefits at similar or lower prices than the plan above. Call 1-888-876-5731 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

New York Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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