Medicare Plan Lookup Official CMS data · Contract Year 2027
CMS 2027 data

2027 Medicare plan code

H3916-057

Medicare Plan

Complete Blue PPO Merit (PPO) · Highmark Blue Cross Blue Shield or Highmark Blue Shield · Local PPO · Western, PA

Full CMS plan ID: H3916-057-000

H3916-057-000 is the full CMS identifier for the H3916-057 Medicare plan. Common searches include H3916 057 and H3916057.

2027

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2027 plan record

Complete Blue PPO Merit (PPO)

H3916-057-000 Western, PA Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–5 $400 / day
Days 6–90 $0 / day
Total of listed copays · 5 charged days $2,000
Out-of-network

Tier 1: $600 / day for days 1–5; $0 / day for days 6–90; $0 per stay

Point of service

Not separately reported

02

Emergency transport

Ambulance

Ground · in-network$340 copay
Air · in-network$340 copay
03

Emergency services

Emergency room

$115 copay

Waived if admitted within 3 days

04

Medical maximum

Maximum out-of-pocket

In-network$8,300
Combined in + out$14,800
05

Skilled care at home

Home health

In-network$0 cost share
Out-of-network30% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0 / month

CMS reports a Part B premium reduction of $82 per month.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkPrimary Care Physician Services: $0 cost share
Out-of-network7a: 40% coinsurance

Specialist

In-networkPhysician Specialist Services: $40 copay
Out-of-network7d: 40% coinsurance

Preventive care

In-networkAnnual Physical Exam: $0 cost share; Kidney Disease Education Services: $0 cost share; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share
Out-of-network14b: $0 cost share; 14d: $0 cost share; 14e1: $0 cost share; 14e2: $0 cost share; 14e4: $0 cost share; 14e5: $0 cost share; 14a: $0 cost share
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-networkDiagnostic Procedures/Tests: $0–$10 copay
Out-of-network8a1: 40% coinsurance

Laboratory services

In-networkLab Services: $0–$50 copay
Out-of-network8a2: 40% coinsurance

X-rays & standard imaging

In-networkOutpatient X-Ray Services: $20 copay
Out-of-network8b3: 40% coinsurance

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $300 copay
Out-of-network8b1: 40% coinsurance
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $40 copay
Out-of-networkNot separately reported

Emergency room

In-network$115 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$340 copay
Out-of-network$340 copay + 30% coinsurance

Air ambulance

In-network$340 copay
Out-of-network$340 copay + 30% coinsurance

Outpatient hospital

In-networkOutpatient Hospital Services: $0–$375 copay; Observation Services: $375 copay
Out-of-network9a1: $475 copay; 9a2: $475 copay

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $0–$325 copay
Out-of-network9b: $475 copay
Recovery & therapy5 benefits

Home health

In-network$0 cost share
Out-of-network30% coinsurance

Skilled nursing facility

In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkSkilled nursing facility: Tier 1: 30% coinsurance

Cardiac & pulmonary rehabilitation

In-networkCardiac Rehabilitation Services: $0 cost share; Intensive Cardiac Rehabilitation Services: $0 cost share; Pulmonary Rehabilitation Services: $0 cost share; SET for PAD Services: $0 cost share; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: 40% coinsurance; 3-2: 40% coinsurance; 3-3: 40% coinsurance; 3-4: 40% coinsurance

Occupational therapy

In-networkOccupational Therapy Services: $35 copay
Out-of-network7c: 40% coinsurance

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $35 copay
Out-of-network7i: 40% coinsurance
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $0 cost share; Individual Sessions for Mental Health Specialty Services: $40 copay; Group Sessions for Mental Health Specialty Services: $40 copay; Individual Sessions for Psychiatric Services: $40 copay; Group Sessions for Psychiatric Services: $40 copay; Inpatient psychiatric hospital: Tier 1: $400 / day for days 1–5; $0 / day for days 6–90
Out-of-network5a: 40% coinsurance; 7e1: 40% coinsurance; 7e2: 40% coinsurance; 7h1: 40% coinsurance; 7h2: 40% coinsurance; Inpatient psychiatric hospital: Tier 1: $475 / day for days 1–5; $0 / day for days 6–90; $0 per stay

Substance use treatment

In-networkIntensive Outpatient Program Services: $0 cost share; Individual Sessions for Outpatient Substance Abuse: $45 copay; Group Sessions for Outpatient Substance Abuse: $45 copay
Out-of-network5b: 40% coinsurance; 9c1: 40% coinsurance; 9c2: 40% coinsurance
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $40 copay; 7f(NMC): $40 copay
Out-of-network7f: 40% coinsurance; 7f_2: 40% coinsurance

Chiropractic

In-networkChiropractic Services: $15 copay
Out-of-network7b: 40% coinsurance
Supplemental benefits7 benefits

Dental

In-networkMedicare Dental Services: $40 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
Out-of-network16a: 40% coinsurance; 16b1: 30% coinsurance; 16b2: 30% coinsurance; 16b4: 30% coinsurance; 16b5: 30% coinsurance; 16c1: 50% coinsurance; 16c2: 50% coinsurance; 16c3: 50% coinsurance; 16c4: 50% coinsurance; 16c7: 50% coinsurance; 16c8: 50% coinsurance; 16c10: 50% coinsurance

Vision

In-networkEye Exams: $0–$40 copay; Other Eye Exam Services: Not applicable; Eyeglasses (lenses and frames): $0–$40 copay; Eyeglass frames: $0–$40 copay
Out-of-network17a: 40% coinsurance; 17a1: $50 copay; 17b: $0 cost share; 17b1: $0 cost share; 17b2: $0 cost share; 17b3: $0 cost share; 17b4: $0 cost share; 17b5: $0 cost share

Hearing

In-networkHearing Exams: $40 copay; Routine Hearing Exams: $20 copay; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $699–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-network18a: 40% coinsurance; 18a1: $20 copay; 18b1: $0 cost share

Transportation

Not applicable
In-network10b(NMC): Not applicable
Out-of-networkNot separately reported

Fitness & wellness

In-networkNot separately reported
Out-of-network14c4: 50% coinsurance

Over-the-counter allowance

Not applicable
In-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported

Meals

Not applicable
In-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$0 Part C premium / month · CMS reports a Part B premium reduction of $82 per month.

Maximum out-of-pocket (MOOP)

In-network$8,300
Combined in + out$14,800

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Annual health deductible

$200

Combined network deductible

Not separately reported

Part D premium

$0 / month

Network & referrals

Local PPO · Referrals: Not required · Out-of-network coverage: Yes

Prescription drugs5 tiers

Part D deductible

$700 / year

Drug tier 1

Standard retail: $7 copay · Preferred retail: $0 copay · 31-day supply

Drug tier 2

Standard retail: $15 copay · Preferred retail: $0 copay · 31-day supply

Drug tier 3

Standard retail: 23% coinsurance · Preferred retail: 23% coinsurance · 31-day supply

Drug tier 4

Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 31-day supply

Drug tier 5

Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 31-day supply

Using this plan

Understand H3916-057-000

Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

Complete Blue PPO Merit (PPO) is a 2027 Local PPO offered by Highmark Blue Cross Blue Shield or Highmark Blue Shield in Western, PA. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $2,000 across 5 charged days.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
Primary Care Physician Services: $0 cost share
Specialist
Physician Specialist Services: $40 copay
Laboratory services
Lab Services: $0–$50 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Diagnostic Procedures/Tests: $0–$10 copay
MRI, CT & PET imaging
Diagnostic Radiological Services: $300 copay
Outpatient hospital
Outpatient Hospital Services: $0–$375 copay; Observation Services: $375 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$115 copay
Listed inpatient stages
$2,000 total

5 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Part B premium reduction (“giveback”)

A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports a Part B premium reduction of $82 per month.

Availability

Who can enroll

Service area
Western, PA (PA)
Plan type
Local PPO
Contract / plan
H3916-057
Coverage year
2027

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

DentalMedicare Dental Services: $40 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
VisionEye Exams: $0–$40 copay; Other Eye Exam Services: Not applicable; Eyeglasses (lenses and frames): $0–$40 copay; Eyeglass frames: $0–$40 copay
HearingHearing Exams: $40 copay; Routine Hearing Exams: $20 copay; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): $699–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Fitness & wellnessNot separately reported

Plan-specific answers

Frequently asked questions

Where is H3916-057-000 available?

Complete Blue PPO Merit (PPO) is listed for Western, PA (PA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H3916-057-000?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $8,300. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H3916-057-000?

The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H3916-057-000?

The plan record lists $115 copay, waived when an admission meets the plan's stated timing rule.

Does H3916-057-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, fitness & wellness. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2027

Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H3916-057-000 fits

Full CMS plan ID
H3916-057-000
Contract
H3916
Base plan code
H3916-057
Segment
000
Carrier
Highmark Blue Cross Blue Shield or Highmark Blue Shield
Plan type
Local PPO
Service area
Western, PA (PA)

County/service-area foundation

CMS service-area entries

Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.

  • Allegheny, PA
  • Armstrong, PA
  • Beaver, PA
  • Butler, PA
  • Erie, PA
  • Fayette, PA
  • Indiana, PA
  • Lawrence, PA
  • Mercer, PA
  • Washington, PA
  • Westmoreland, PA

Exact county navigation

These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.

Show 11 county links

Same CMS contract

H3916-001-000 Freedom Blue PPO Classic (PPO) Southwestern PA · Local PPO H3916-002-000 Freedom Blue PPO Classic (PPO) West Central PA · Local PPO H3916-005-000 Freedom Blue PPO Deluxe (PPO) Central and Northeastern PA · Local PPO H3916-012-000 Freedom Blue PPO Basic (PPO) Central and Northeastern PA · Local PPO H3916-015-000 Freedom Blue PPO Standard (PPO) Central and Northeastern PA · Local PPO H3916-018-000 Freedom Blue PPO ValueRx (PPO) Central and Northeastern PA · Local PPO H3916-022-000 Freedom Blue PPO Select (PPO) Southwestern PA · Local PPO H3916-024-000 Freedom Blue PPO Select (PPO) West Central PA · Local PPO

About this code

What H3916-057-000 identifies

H3916-057-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H3916-057, H3916 057, or the compact full CMS ID H3916057000 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.