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Complete Blue PPO Choice Deluxe (PPO)

H3916 - 050 - 1
4.5 out of 5 stars (4.5 / 5)

Complete Blue PPO Choice Deluxe (PPO) is a Medicare Advantage Plan by Highmark Blue Cross Blue Shield or Highmark Blue Shield.

This page features plan details for 2025 Complete Blue PPO Choice Deluxe (PPO) H3916 – 050 – 1 available in North Central PA.

Locations

Complete Blue PPO Choice Deluxe (PPO) is offered in the following locations.

Carbon County, Pennsylvania
Lehigh County, Pennsylvania
Monroe County, Pennsylvania

Click to see more locations

Plan Overview

Complete Blue PPO Choice Deluxe (PPO) offers the following coverage and cost-sharing.

Insurer:Highmark Blue Cross Blue Shield or Highmark Blue Shield
Health Plan Deductible:$0
MOOP:$8,950 In and Out-of-network
$6,400 In-network
Drugs Covered:Yes

Ready to sign up for Complete Blue PPO Choice Deluxe (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Complete Blue PPO Choice Deluxe (PPO) has a monthly premium of $7.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $2.70 $4.30 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Complete Blue PPO Choice Deluxe (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$4.30$4.30

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Complete Blue PPO Choice Deluxe (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: 0-50 Coins – No Co pay
  • Endodontics
    • In-Network: 50 Coins – No Co pay
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay
  • Periodontics
    • In-Network: 50 Coins – No Co pay
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay
  • Restorative Services
    • In-Network: 50 Coins – No Co pay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $295 copay (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $20 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $295 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $0 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $20 copay (Authorization Required)

Doctor visits

  • Specialist
    • In-Network: $25 copay per visit
    • Out-of-Network: $25 copay per visit
  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $50 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $25 copay
    • Out-of-Network: $25 copay
  • Routine foot care
    • In-Network: $25 copay (Limits Apply)

Ground ambulance

    • In-Network: $280 copay
    • Out-of-Network: $280 copay or 30% coinsurance

Health plan deductible

    • $0

Hearing

  • Medicare-Covered Hearing Exam
    • In-Network: $25 copay
  • Hearing aids
    • Out-of-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $25 copay
  • Fitting/evaluation
    • Not covered
  • Hearing aids
    • In-Network: $699-999 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered

Inpatient hospital coverage

    • In-Network: $415 per stay (Authorization Required)
    • Out-of-Network: $415 per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $8,950 In and Out-of-network
      $6,400 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit
    • In-Network: $30 copay
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $30 copay
  • Inpatient hospital – psychiatric
    • In-Network: $425 per day for days 1 through 3
      $0 per day for days 4 through 90 (Authorization Required)
    • Out-of-Network: $425 per day for days 1 through 3
      $0 per day for days 4 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $30 copay
  • Outpatient group therapy visit
    • Out-of-Network: $30 copay
  • Outpatient individual therapy visit
    • Out-of-Network: $30 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $30 copay
  • Outpatient individual therapy visit
    • In-Network: $30 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $30 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: $350 copay per visit (Authorization Required)
    • In-Network: $350 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $20 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $20 copay (Authorization Required)
    • In-Network: $20 copay (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: $20 copay (Authorization Required)

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 30% per stay (Authorization Required)

Transportation

    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)

Vision

  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $50 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Complete Blue PPO Choice Deluxe (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Complete Blue PPO Choice Deluxe (PPO)? See 2025 Complete Blue PPO Choice Deluxe (PPO) at MedicareAdvantageRX.com.

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