Complete Blue PPO Choice (PPO)

Inpatient Hospital See details

Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $170 copay for days 1-3, and no copay for days 4-90, while Inpatient Hospital Psychiatric has a $425 copay for days 1-3, and no copay for days 4-90. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.

Outpatient Services See details

Outpatient Services include coverage for Outpatient Hospital Services and Observation Services, each with a $350 copay, Ambulatory Surgical Center (ASC) Services with a $250 copay, and Outpatient Substance Abuse Services with a $45 copay for both individual and group sessions. Outpatient Blood Services are also covered, with a waived three-pint deductible.

Partial Hospitalization See details

Partial Hospitalization benefits are covered by the Complete Blue PPO Choice (PPO) plan. There is no information about the cost of these services.

Ambulance and Transportation Services See details

Ambulance and Transportation Services are covered under the Complete Blue PPO Choice (PPO) plan. Ground and air ambulance services each have a $250 copay, and there is no coinsurance. Transportation services to a plan-approved health-related location are covered, while transportation services to any health-related location are not covered.

Emergency Services See details

Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Complete Blue PPO Choice (PPO) plan. Emergency Services have a $110 copay with no coinsurance, Urgently Needed Services have a $30 copay with no coinsurance, Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $30 copay, and Worldwide Emergency Transportation has a $250 copay, all with no coinsurance.

Primary Care See details

Complete Blue PPO Choice (PPO) covers primary care, chiropractic, occupational therapy, and other services. Chiropractic services have a $15 copay and require prior authorization; occupational therapy services have a $25 copay and require authorization.

Physician specialist services have a $30 copay, and mental health specialty services have a $40 copay for individual and group sessions.

Podiatry services have a $30 copay for Routine Foot Care.

Other Health Care Professional services have a copay between $0 and $30, psychiatric services have a $40 copay for individual and group sessions, and physical therapy and speech-language pathology services have a $25 copay and require authorization.

Additional Telehealth Benefits have a copay between $0 and $45, and Opioid Treatment Program Services have a $45 copay.

Preventive Services See details

Preventive Services are covered, including Annual Physical Exams, Medicare-covered Zero Dollar Preventive Services, and other preventive services. Additional preventive services, Fitness Benefit, Enhanced Disease Management, Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered. Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) has a copay between $0 and $30, and Home and Bathroom Safety Devices and Modifications has 20% coinsurance. Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, and Counseling Services are not covered.

Hearing Services See details

The Complete Blue PPO Choice (PPO) plan covers hearing exams with a $30 copay, with routine hearing exams covered for 1 visit per year with a copay between $20 and $20. Prescription hearing aids are covered with a maximum benefit of $500 per year and a copay between $699 and $999, while fitting/evaluation for hearing aids, prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.

Vision Services See details

Vision Services include routine eye exams with a $30 copay, along with coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades; a combined maximum benefit of $350 applies to eyewear annually.

Dental Services See details

Dental Services are covered, with a $30 copay for Medicare Dental Services. Other dental services have a $3,500 annual maximum, and include coverage for oral exams, dental x-rays, cleaning, fluoride treatment, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with 50% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered by the Complete Blue PPO Choice (PPO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0-20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0-20%.

Dialysis Services See details

Dialysis Services are covered by the Complete Blue PPO Choice (PPO) plan, with a coinsurance between 20% and 20%.

Medical Equipment See details

Medical Equipment is covered, including Durable Medical Equipment with 20% coinsurance and Prosthetic Devices, and Medical Supplies with 20% coinsurance. Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic procedures and lab services are not covered. Diagnostic Radiological Services have a maximum copay of $250, Therapeutic Radiological Services have a maximum copay of $75, and Outpatient X-Ray Services have a $25 copay.

Home Health Services See details

Home Health Services are covered by the Complete Blue PPO Choice (PPO) plan. There is no copay or coinsurance for this benefit, but authorization is required.

Cardiac Rehabilitation Services See details

Cardiac Rehabilitation Services are technically covered, but not covered in practice. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) benefits are covered by the Complete Blue PPO Choice (PPO) plan, with prior authorization required. You will have no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.

Other Services See details

The Complete Blue PPO Choice (PPO) plan does not cover acupuncture, meal benefits, or services for Dual Eligible SNPs with Highly Integrated Services. The plan covers Over-the-Counter (OTC) Items, but does not cover all drugs on the CMS OTC list. Additionally, the plan does not cover Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.