MedicareCommons™

Neutral. Transparent. Retrieval-first.

array(20) { ["plan_name"]=> string(32) "Complete Blue PPO Distinct (PPO)" ["plan_id"]=> string(9) "H3916-035" ["org_name"]=> string(55) "Highmark Blue Cross Blue Shield or Highmark Blue Shield" ["plan_type"]=> string(9) "Local PPO" ["region"]=> string(10) "Western PA" ["moop"]=> string(12) "Data missing" ["deductible"]=> string(12) "Data missing" ["inpatient_hospital"]=> string(58) "Not Covered
Prior Authorization Required" ["snf"]=> string(91) "$0.00 (days 1–20), $214.00 (days 21–100)
Prior Authorization Required" ["pcp"]=> string(17) "% - % Coinsurance" ["specialist"]=> string(59) "$15.00 Copay
Prior Authorization Required" ["urgent_care"]=> string(59) "$30.00 Copay
Prior Authorization Required" ["er"]=> string(60) "$200.00 Copay
Prior Authorization Required" ["ambulance_ground"]=> string(60) "$260.00 Copay
Prior Authorization Required" ["ambulance_air"]=> string(60) "$260.00 Copay
Prior Authorization Required" ["dental"]=> string(45) "$3,000.00 max
$3,000.00 max" ["vision"]=> string(54) "% - % Coinsurance
$400.00/yr eyewear" ["hearing"]=> string(11) "Not Covered" ["rx"]=> array(2) { ["deductible"]=> string(5) "$0.00" ["tiers"]=> array(5) { [0]=> array(11) { ["order"]=> int(1) ["name"]=> string(17) "Preferred Generic" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(11) "$7.00 Copay" ["retail_90"]=> string(12) "$21.00 Copay" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(12) "$21.00 Copay" ["ltc_30"]=> string(11) "$7.00 Copay" ["out_network"]=> string(11) "$7.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } [1]=> array(11) { ["order"]=> int(2) ["name"]=> string(7) "Generic" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(12) "$20.00 Copay" ["retail_90"]=> string(12) "$60.00 Copay" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(12) "$60.00 Copay" ["ltc_30"]=> string(12) "$20.00 Copay" ["out_network"]=> string(12) "$20.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } [2]=> array(11) { ["order"]=> int(3) ["name"]=> string(15) "Preferred Brand" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "25% Coinsurance" ["retail_90"]=> string(15) "25% Coinsurance" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(15) "25% Coinsurance" ["ltc_30"]=> string(15) "25% Coinsurance" ["out_network"]=> string(15) "25% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } [3]=> array(11) { ["order"]=> int(4) ["name"]=> string(18) "Non-Preferred Drug" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "50% Coinsurance" ["retail_90"]=> string(15) "50% Coinsurance" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(15) "50% Coinsurance" ["ltc_30"]=> string(15) "50% Coinsurance" ["out_network"]=> string(15) "50% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } [4]=> array(11) { ["order"]=> int(5) ["name"]=> string(9) "Specialty" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "33% Coinsurance" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(15) "33% Coinsurance" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(15) "33% Coinsurance" ["out_network"]=> string(15) "33% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } } } ["data_status"]=> string(2) "ok" }
🩺 Doctor’s Office Visits
Service 2026 2025
PrimaryComing soon% - % Coinsurance
SpecialistComing soon$15.00 Copay
Prior Authorization Required
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
Service 2026 2025
Emergency room careComing soon$200.00 Copay
Prior Authorization Required
Urgent careComing soon$30.00 Copay
Prior Authorization Required
Ground ambulanceComing soon$260.00 Copay
Prior Authorization Required
Inpatient hospital careComing soonNot Covered
Prior Authorization Required
Skilled Nursing FacilityComing soon$0.00 (days 1–20), $214.00 (days 21–100)
Prior Authorization Required
🦶 Foot Care
Service 2026 2025
Foot Exams and Treatments (Medicare-covered)Coming soon20% Coinsurance
Routine Foot CareComing soon0% - 20% Coinsurance
Prior Authorization Required
💆 Chiropractic Care
Service 2026 2025
Medicare-covered chiropracticComing soon20% Coinsurance
Prior Authorization Required
Routine chiropracticComing soon20% Coinsurance
Prior Authorization Required
🧠 Mental Health Services
Service 2026 2025
Outpatient individual therapyComing soon% - % Coinsurance
Outpatient group therapyComing soon% - % Coinsurance
Inpatient psychiatric hospital careComing soon$425.00 (days 1–3), $0.00 (days 4–90)
Prior Authorization Required
🏋️ Rehabilitation Services
Service 2026 2025
Physical therapy and speech/language therapyComing soon$10.00 Copay
Occupational therapyComing soon$40.00 Copay
🧰 Medical Equipment and Supplies
Service 2026 2025
Diabetes suppliesComing soon% - % Coinsurance
Prior Authorization Required
Durable medical equipmentComing soon$10.00 Copay
4 visits/yr
ProstheticsComing soon$0.00 - $10.00 Copay
🔬 Diagnostics, Lab Services, and Imaging
Service 2026 2025
Diagnostic radiology servicesComing soon$40.00 Copay
Lab servicesComing soon$5.00 Copay
Prior Authorization Required
Outpatient x-raysComing soon$0.00 - $45.00 Copay
Diagnostic tests and proceduresComing soon$45.00 Copay
💉 Medicare Part B Drugs
Service 2026 2025
ChemotherapyComing soon0% - 20% Coinsurance
Prior Authorization Required
Other Part B drugs (Medicare-covered)Coming soon20% Coinsurance
Prior Authorization Required

Supplemental Benefits

🦷 Dental Services
Service 2026 2025
Medicare Covered Preventive DentalComing soon$3,000.00 max
$3,000.00 max
Oral examComing soon% - % Coinsurance
Dental x-raysComing soon% - % Coinsurance
CleaningComing soonNot Covered
PeriodonticsComing soon10% Coinsurance
EndodonticsComing soon10% Coinsurance
Restorative ServicesComing soon10% Coinsurance
Dental MaximumComing soon$3000.00 max
👂 Hearing Aids and Services
Service 2026 2025
Fitting/evaluationComing soon$10.00 Copay
Hearing aidsComing soon$699.00 - $999.00 Copay
Hearing examComing soonNot Covered
Hearing MaximumComing soonNot Covered
👓 Vision Services
Service 2026 2025
Medicare-covered eye examComing soonNot Covered
Routine eye examComing soon% - % Coinsurance
Eyewear benefitsComing soon% - % Coinsurance
Vision Eyewear MaximumComing soon$400.00/yr eyewear
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Part D Plan Premium

The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.

{name} Prescription Drug Plan Premium Details
Basic Part D Premium: ${part_d_basic_premium}
Supplemental Part D Premium: ${part_d_supplemental_premium}
Total Part D Premium: ${part_d_total_premium}
Low-Income Premium Subsidy: ${part_d_lips_amount}
Low-Income Premium Subsidy Paid by CMS: ${part_d_lips_cms_pays}
Low-Income Subsidy Premium: ${part_d_lis_premium}

For more details, visit the Social Security Extra Help program.

Prescription Drug Plan Deductible

This plan has a ${deductible} annual Part D deductible. You'll pay this deductible at the pharmacy before {carrier} starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, {name} may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

{name} Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
Preferred Generic30-day: $7.00 Copay
90-day: $21.00 Copay		30-day: —
90-day: $21.00 Copay
Generic30-day: $20.00 Copay
90-day: $60.00 Copay		30-day: —
90-day: $60.00 Copay
Preferred Brand30-day: 25% Coinsurance
90-day: 25% Coinsurance		30-day: —
90-day: 25% Coinsurance
Non-Preferred Drug30-day: 50% Coinsurance
90-day: 50% Coinsurance		30-day: —
90-day: 50% Coinsurance
Specialty30-day: 33% Coinsurance
90-day: —		30-day: 33% Coinsurance
90-day: —
*Deductible does not apply.