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Complete Blue PPO Signature (PPO) - H5106-035-000

3.5 out of 5 stars* for plan year 2026

$0.00

Monthly Premium

Complete Blue PPO Signature (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health

Plan ID: H5106-035-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

West Virginia Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.

Learn more about West Virginia Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price. 

Enrollment may be limited to certain times of the year. See why you may be able to enroll today.

Compare plans today.

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Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$615.00
Out-of-pocket maximum$7,550.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,100.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45
Inpatient hospital care
Out-of-Network:

Acute Hospital Services:
$425 per day for days 1 to 5
$0 per day for days 6 to 90
Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care.
Urgent care
Urgent Care:
Copayment for Urgent Care $40

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40
Emergency room visit
Emergency Care:
Copayment for Emergency Care $115

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $115
Copayment for Worldwide Emergency Transportation $560
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $560
Coinsurance for Medicare Covered Ambulance Services - Ground 30%
Copayment for Medicare Covered Ambulance Services - Air $560
Coinsurance for Medicare Covered Ambulance Services - Air 30%
Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip.

Health Care Services and Medical Supplies

Complete Blue PPO Signature (PPO) covers a range of additional benefits. Learn more about Complete Blue PPO Signature (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 40%
Diabetes supplies, training, nutrition therapy and monitoring

In-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Glucometers, test strips, lancets, control solution, replacement batteries, platforms, lens shield, and non-invasive vagus nerve stimulator are supplied at the minimum coinsurance. All other Medicare covered Diabetic Supplies at the maximum coinsurance.Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to Abbott and Trividia. Continuous glucose monitors, sensors and transmitters dispensed via retail or mail order pharmacy are limited to Abbott and Dexcom. All other desired brands will need to be obtained via an exception process or from a Durable Medical Equipment (DME) supplier.

Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-rays


Out-of-Network:

Diagnostic Procedures/Tests Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%

Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
$500 per day for days 1 to 3
$0 per day for days 4 to 90
Private accommodations will be covered when medically necessary. Inpatient substance abuse is subject to the same cost sharing as Inpatient Psychiatric Hospital.
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $350
Prior Authorization Required for Outpatient Hospital Services
Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $350
Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment.

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $300
Prior Authorization Required for Ambulatory Surgical Center Services
Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment.
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Over-the-counter items


Out-of-Network:

Over-The-Counter (OTC) Items Services:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0
Maximum Plan Benefit of $25
An OTC catalog of CMS-approved non-prescription over-the-counter medications and health-related items is available. Quantity limits and plan restrictions may apply.

Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45
Copayment for Routine Foot Care $45
  • Maximum 10 visits every year
Skilled Nursing Facility (SNF) care
Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 30%
Private accommodations will be covered when medically necessary.

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental care

In-Network:

Medicare Covered Dental:
Copayment for Office Visit $45

Non-Medicare Covered Preventive Dental:

Copayment for Oral exams $0

  • Maximum 2 visits every year

Copayment for Dental x-rays $0

  • Maximum 1 visit every year

Copayment for Prophylaxis $0

  • Maximum 2 visits every year

Copayment for Fluoride treatment $0

  • Maximum 2 visits every year



Non-Medicare Covered Comprehensive Dental:

Coinsurance for Restorative services 50%

Coinsurance for Endodontics 50%

Coinsurance for Periodontics 50%

Coinsurance for Prothodontics, removable 50%

Coinsurance for Prothodontics, fixed 50%

Coinsurance for Maxillofacial surgery 50%

Coinsurance for Adjunctive general services 0% to 50%

Maximum Plan Benefit of $2,000 every year

Please see Evidence of Coverage for details

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision care


Out-of-Network:

Eye Exams Services:
Coinsurance for Medicare Covered Eye Exams 40%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing care

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Hearing Exams $25

  • Maximum 1 visit every year


Hearing Aids:
Copayment for Hearing Aids $699 to $999

  • Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $500 every year for any other hearing aid.
Members must use our contracted provider to use this benefit. Up to two hearing aids every year (one per ear per year). Benefit is limited to the Advanced (minimum cost sharing) and Premium (maximum cost sharing) hearing aids, which come in various styles and colors, and are available in rechargeable style options at no additional charge. Hearing aid purchase includes:- First year of follow-up provider visits- 60-day trial period- 3-year extended warranty- 80 batteries per aid for non-rechargeable models Benefit does not include or cover any of the following:• Additional cost for optional hearing aid rechargeability • Ear molds• Hearing aid accessories• Additional provider visits• Additional batteries - batteries when a rechargeable hearing aid is purchased• Hearing aids that are not TruHearing-branded hearing aids• Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan.Services not covered under any condition:Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), ear molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the 80 free batteries per non-rechargeable aid purchased).Members have a $500 maximum allowance towards hearing aids that are not the Advanced or Premium models.

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0

Prescription Drug Costs and Coverage

The Complete Blue PPO Signature (PPO) offers prescription drug coverage, with an annual drug deductible of $615.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$615.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $7.00
  • Preferred mail order N/A
  • Standard mail order N/A
Tier 2
  • Preferred retail $3.00
  • Standard retail $15.00
  • Preferred mail order N/A
  • Standard mail order N/A
Annual drug deductible$615.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail N/A
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
Tier 2
  • Preferred retail N/A
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
Annual drug deductible$615.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $21.00
  • Preferred mail order $0.00
  • Standard mail order $21.00
Tier 2
  • Preferred retail $9.00
  • Standard retail $45.00
  • Preferred mail order $7.00
  • Standard mail order $45.00

When reviewing West Virginia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of West Virginia that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

West Virginia Counties Served

We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Healthspring, Wellcare, or Kaiser Permanente.

Enrollment may be limited to certain times of the year. See why you may be able to enroll today.

Back to plans in West Virginia

Compare plans today.

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