Forever Blue 770 (PPO)
Our Forever Blue 770 (PPO) Medicare Advantage Plan is designed to make Medicare easy for you. If you travel often, you can enjoy the flexibility of Medicare Advantage network sharing. You'll pay the same as you would in-network for all plan-covered services outside of Northeastern New York participating areas. It is designed to give you the freedom to see any doctor or hospital that accepts Medicare nationwide.
Forever Blue 770 (PPO)
PRIMARY/SPECIALTY
$5/$22
DRUG DEDUCTIBLES
$0
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 | $22 |
Use our new 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 | $10 | $15 |
| Tier 3 | $42 | $47 |
| Tier 4 | $94 | $100 |
| Tier 5 | 33% | 33% |
The Medicare Part D Coverage Gap
The 'coverage gap' or 'donut hole' is a Part D drug coverage stage that 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.
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 out-of-pocket per year |
| Outpatient hospital | $275 |
| Ambulatory surgery | $175 |
| X-rays | $40 |
| Advanced radiology | $150 |
| Lab copayment | $5 |
Preventive Dental
All our plans include preventive dental coverage:
- Routine cleanings/oral exams - twice per year ($15 copay per service).
- X-rays - four bitewing or one full-month X-ray per year ($15 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 | $13 | 50% coinsurance | $500 |
| Enhanced | $24 | 50% coinsurance | $1,000 |
Note: Preventive services do not count toward the annual max allowance for dental.
Plan Highlights
| Worldwide coverage for emergency and urgent care | $90 Emergency care; $65 Urgent care |
| 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 in network and $10,000 combined in and out of network |
**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.
Medicare Questions?
We're here to help.
1-833-735-4512 (TTY 711)
Oct. 1 - March 31, 8 a.m. - 8 p.m., 7 days a week
April 1 - Sept. 30, 8 a.m. - 8 p.m., Monday - Friday
Frequently Asked Questions
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Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BSNENY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BSNENY 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