Forever Blue 751 (PPO)
BlueCard® Network Sharing Program
All of our plans cover you worldwide but if you travel often, you can enjoy flexibility with the Medicare Advantage Network Sharing Program through this plan.
- Links Blue Cross plans and simplifies billing.
- Pay the same as you would in-network for all plan-covered services outside of Western New York in participating areas.**
- Find out if a doctor or facility participates in this program by calling 1-800-810-BLUE (2583) and select option 2.
**In order for services to be considered in-network while you're outside of the service area, the provider must participate with the local BlueCard® network sharing program in the service area and both you and the provider must be located in the same area when you receive care. Outside the U.S. you may be asked to pay 100% of the cost at the time of travel. You would then submit a claim to us to be reimbursed for your in-network cost-share.
premium
Forever Blue 751 (PPO)
premium
Pay in-network copays for all plan-covered services when you receive care outside of Western New York with BlueCard travel.
PRIMARY/SPECIALTY
$5/$25
DRUG DEDUCTIBLES
N/A
INPATIENT HOSPITAL
$205 per day for days 1-7,
$1,435 OOP Max per year
Forever Blue 770 (PPO) Plan Details
Primary Care Doctor/Specialist
| Primary Care Doctor | Specialist |
|---|---|
| $5 | $25 |
Use our Find a Doctor tool to discover if your doctor, specialist, or facility are in-network.
If they are not in-network, you can search to find one that is in our network of providers.
Part D Prescription Drugs
| Drug Deductibles | $0 |
| Part D Prescriptions: | Preferred Pharmacy | Standard Pharmacy |
|---|---|---|
| Tier 1 | $2 | $7 |
| Tier 2 | $8 | $13 |
| Tier 3 | $42 | $47 |
| Tier 4 | $94 | $99 |
| Tier 5 | 33% | 33% |
$0 Tier 1 Generics with Convenient Home Delivery
$0 copay for a 90-day supply of Tier 1 preferred generic medications delivered for free through Express Scripts® mail order during the initial coverage stage.
The Medicare Part D Coverage Gap
The 'coverage gap' or 'donut hole' is a Part D drug coverage stage the changes what you pay for prescriptions. You may not end up in the coverage gap each year, but you should be aware of how it works, just in case.
Prescription Drug Information
The 2022 Medicare Formulary includes a list of prescription care drugs covered by a prescription drug plan.
Surgery & Treatment
| Inpatient hospital | $205/day, days 1-7 / $1,435 max per year |
| Outpatient hospital | $300 |
| Ambulatory surgery | $200 |
| X-rays | $40 |
| Advanced radiology | $150 |
| Lab | $5 |
Preventive Dental
All of our plans include preventive dental coverage:
- Routine cleanings/oral exams - twice per year ($10 copay per service).
- X-rays - four bitewing or one full-month X-ray per year ($10 copay per service).
Optional Supplemental Dental is also available:
You may add dental care with the following optional supplemental benefits (no network - see any dentist):
| Premium | Diagnostic and Restorative Service Cost | Annual Max Allowance | |
|---|---|---|---|
| Basic | $12 | 50% coinsurance | $500 |
| Enhanced | $25 | 50% coinsurance | $1,000 |
Plan Highlights
| World coverage for emergency and urgent care | $90/$65 |
| Part B diabetes supplies and monitors | $0 |
| Skilled nursing facility days 1-20 | $0 |
| Skilled nursing facility days 21-100 | $188/day |
| Hearing aid (specific models)* | $599 or $899/unit |
| In-network out-of-pocket maximum | $6,700 |
*Our plans cover one routine hearing exam per year with a TruHearing® provider. Please call TruHearing to verify your benefit and schedule a hearing exam. Hearing aid $599 or $899/unit (one per ear, per year, specific models).
This past January, the Centers for Medicare & Medicaid Services (CMS) added acupuncture as a covered benefit for Medicare patients with chronic low back pain. According to CMS, coverage will include "up to 12 sessions in 90 days with an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement." Treatment must also be recommended and supervised by a doctor.
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Highmark Blue Cross Blue Shield of Western New York (Highmark BCBSWNY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BCBSWNY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BCBSWNY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711).
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Content last updated: October 1, 2021