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Highmark Coverage Go-To Guide
The Visitor/Travel Program will include Blue Medicare Advantage PPO network coverage of all Part A, Part B, and Supplemental benefits offered by your plan outside your service area in 31 states and 1 territory: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, North Carolina, New York, Ohio, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin. For some of the states listed, MA PPO networks are only available in portions of the state. Y Highmark our Coverage Go-To Guide 2189DP As a Highmark member, you have the same in-network benefits and low costs at home and across the country. Whether you’re heading where it’s warm for the winter or just taking a weekend trip, you’ll receive in-network level benefits in all counties listed in this booklet. Wherever you go, it’s easy to find a provider. Go online to the “Doctor and Hospital Finder” at http://provider.bcbs.com and follow the simple search instructions. Under Medicare Advantage rules, if you are absent from the service area for more than six (6) months, you must be disenrolled. However, in areas where we offer the Visitor/Travel Program you may remain in the plan while out of our service area for 6 months. Members who see Medicare Advantage PPO providers in any geographic area where the Visitor/Travel Program is offered will pay the same cost-sharing level (innetwork cost-sharing) they would pay if they received covered benefits from in-network providers in their service area. Highmark, Inc. is a Health plan with a Medicare contract. Highmark Health Insurance Company is a Health plan with a Medicare contract. Highmark is a registered mark of Highmark Inc. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Highmark Health Insurance Company is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Freedom Blue is a service mark of the Blue Cross and Blue Shield Association. Stay in network — even when you’re out of town. If you’re enrolled in a Highmark Medicare Advantage PPO plan, you can call Member Service using the phone number that’s printed on the back of your Freedom Blue PPO Member ID card. If you have your enrollment forms and are thinking about becoming a member, you can find nationwide providers by calling the phone or TTY number listed on your enrollment materials. In-network coverage from coast to coast Coverage at home: • Access to participating doctors and hospitals wherever you go in Pennsylvania, West Virginia, New York, Ohio and New Jersey. • More choice through one of the largest Medicare Advantage PPO networks in the state. • Over 34,000 doctors, specialists and hospitals in Pennsylvania and West Virginia. • High standards of quality — Every participating Freedom Blue PPO provider is carefully screened before admission to the network. Then each is reviewed regularly to ensure you continue to receive the highest quality of care. Coverage when you travel: • The same level of care and coverage nationwide from any participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider or hospital. • Coverage in 31 states and 1 territory, including Florida, California, the Carolinas, New York, Texas, Puerto Rico and more. The highest level of emergency benefits — anywhere No matter where you are, emergency and urgent care are always covered at the highest level of coverage. H3916_H5106_12_0576 Accepted The Visitor/Travel Program will include Blue Medicare Advantage PPO network coverage of all Part A, Part B, and Supplemental benefits offered by your plan outside your service area in 31 states and 1 territory: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, North Carolina, New York, Ohio, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin. For some of the states listed, MA PPO networks are only available in portions of the state. Y Highmark our Coverage Go-To Guide 2189DP As a Highmark member, you have the same in-network benefits and low costs at home and across the country. Whether you’re heading where it’s warm for the winter or just taking a weekend trip, you’ll receive in-network level benefits in all counties listed in this booklet. Wherever you go, it’s easy to find a provider. Go online to the “Doctor and Hospital Finder” at http://provider.bcbs.com and follow the simple search instructions. Under Medicare Advantage rules, if you are absent from the service area for more than six (6) months, you must be disenrolled. However, in areas where we offer the Visitor/Travel Program you may remain in the plan while out of our service area for 6 months. Members who see Medicare Advantage PPO providers in any geographic area where the Visitor/Travel Program is offered will pay the same cost-sharing level (innetwork cost-sharing) they would pay if they received covered benefits from in-network providers in their service area. Highmark, Inc. is a Health plan with a Medicare contract. Highmark Health Insurance Company is a Health plan with a Medicare contract. Highmark is a registered mark of Highmark Inc. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Highmark Health Insurance Company is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Freedom Blue is a service mark of the Blue Cross and Blue Shield Association. Stay in network — even when you’re out of town. If you’re enrolled in a Highmark Medicare Advantage PPO plan, you can call Member Service using the phone number that’s printed on the back of your Freedom Blue PPO Member ID card. If you have your enrollment forms and are thinking about becoming a member, you can find nationwide providers by calling the phone or TTY number listed on your enrollment materials. In-network coverage from coast to coast Coverage at home: • Access to participating doctors and hospitals wherever you go in Pennsylvania, West Virginia, New York, Ohio and New Jersey. • More choice through one of the largest Medicare Advantage PPO networks in the state. • Over 34,000 doctors, specialists and hospitals in Pennsylvania and West Virginia. • High standards of quality — Every participating Freedom Blue PPO provider is carefully screened before admission to the network. Then each is reviewed regularly to ensure you continue to receive the highest quality of care. Coverage when you travel: • The same level of care and coverage nationwide from any participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider or hospital. • Coverage in 31 states and 1 territory, including Florida, California, the Carolinas, New York, Texas, Puerto Rico and more. The highest level of emergency benefits — anywhere No matter where you are, emergency and urgent care are always covered at the highest level of coverage. H3916_H5106_12_0576 Accepted The Visitor/Travel Program will include Blue Medicare Advantage PPO network coverage of all Part A, Part B, and Supplemental benefits offered by your plan outside your service area in 31 states and 1 territory: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, North Carolina, New York, Ohio, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin. For some of the states listed, MA PPO networks are only available in portions of the state. Y Highmark our Coverage Go-To Guide 2189DP As a Highmark member, you have the same in-network benefits and low costs at home and across the country. Whether you’re heading where it’s warm for the winter or just taking a weekend trip, you’ll receive in-network level benefits in all counties listed in this booklet. Wherever you go, it’s easy to find a provider. Go online to the “Doctor and Hospital Finder” at http://provider.bcbs.com and follow the simple search instructions. Under Medicare Advantage rules, if you are absent from the service area for more than six (6) months, you must be disenrolled. However, in areas where we offer the Visitor/Travel Program you may remain in the plan while out of our service area for 6 months. Members who see Medicare Advantage PPO providers in any geographic area where the Visitor/Travel Program is offered will pay the same cost-sharing level (innetwork cost-sharing) they would pay if they received covered benefits from in-network providers in their service area. Highmark, Inc. is a Health plan with a Medicare contract. Highmark Health Insurance Company is a Health plan with a Medicare contract. Highmark is a registered mark of Highmark Inc. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Highmark Health Insurance Company is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Freedom Blue is a service mark of the Blue Cross and Blue Shield Association. Stay in network — even when you’re out of town. If you’re enrolled in a Highmark Medicare Advantage PPO plan, you can call Member Service using the phone number that’s printed on the back of your Freedom Blue PPO Member ID card. If you have your enrollment forms and are thinking about becoming a member, you can find nationwide providers by calling the phone or TTY number listed on your enrollment materials. In-network coverage from coast to coast Coverage at home: • Access to participating doctors and hospitals wherever you go in Pennsylvania, West Virginia, New York, Ohio and New Jersey. • More choice through one of the largest Medicare Advantage PPO networks in the state. • Over 34,000 doctors, specialists and hospitals in Pennsylvania and West Virginia. • High standards of quality — Every participating Freedom Blue PPO provider is carefully screened before admission to the network. Then each is reviewed regularly to ensure you continue to receive the highest quality of care. Coverage when you travel: • The same level of care and coverage nationwide from any participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider or hospital. • Coverage in 31 states and 1 territory, including Florida, California, the Carolinas, New York, Texas, Puerto Rico and more. The highest level of emergency benefits — anywhere No matter where you are, emergency and urgent care are always covered at the highest level of coverage. H3916_H5106_12_0576 Accepted Access in-network benefits across the country Seattle WA Olympia Milwaukee MT ID Portland ME ND MN OR VT WI NH SD Boise WY Salt Lake City CA MI Las Vegas UT CO KS Denver AZ OK NM PA IA NE NV MA CT NY MO St. Louis IL VA KY SC Little Rock Dallas TX Austin MS Houston Atlanta GA AL Savannah Jacksonville Orlando LA Pensacola San Antonio Richmond Roanoke Greensboro Raleigh NC TN AR Jonesboro DE MD DC WV Springfield FL St. Petersburg HI RI NJ OH IN Boston Fort Lauderdale Miami AK PR 2013 Medicare Advantage PPO Network-Sharing Counties Participating Counties See your County-by-County Coverage Listing ALABAMA (EVERY COUNTY) AUTAUGA HOUSTON BALDWIN JACKSON BARBOUR JEFFERSON BIBB LAMAR BLOUNT LAUDERDALE BULLOCK LAWRENCE BUTLER LEE CALHOUN LIMESTONE CHAMBERS LOWNDES CHEROKEE MACON CHILTON MADISON CHOCTAW MARENGO CLARKE MARION CLAY MARSHALL CLEBURNE MOBILE COFFEE MONROE COLBERT MONTGOMERY CONECUH MORGAN COOSA PERRY COVINGTON PICKENS CRENSHAW PIKE CULLMAN RANDOLPH DALE RUSSELL DALLAS SAINT CLAIR DEKALB SHELBY ELMORE SUMTER ESCAMBIA TALLADEGA ETOWAH TALLAPOOSA FAYETTE TUSCALOOSA FRANKLIN WALKER GENEVA WASHINGTON GREENE WILCOX HALE WINSTON HENRY CALIFORNIA (CONT.) CALAVERAS COLUSA CONTRA COSTA DEL NORTE EL DORADO FRESNO GLENN HUMBOLDT IMPERIAL INYO KERN KINGS LAKE LASSEN LOS ANGELES MADERA MARIN MARIPOSA MENDOCINO MERCED MODOC MONO MONTEREY NAPA NEVADA ORANGE PLACER ARKANSAS CRAIGHEAD GREENE CONNECTICUT (EVERY COUNTY) FAIRFIELD NEW HAVEN HARTFORD NEW LONDON LITCHFIELD TOLLAND MIDDLESEX WINDHAM POINSETT PULASKI CALIFORNIA (EVERY COUNTY) ALAMEDA AMADOR ALPINE BUTTE COLORADO ADAMS ARAPAHOE BROOMFIELD DENVER DOUGLAS PLUMAS RIVERSIDE SACRAMENTO SAN BENITO SAN BERNARDINO SAN DIEGO SAN FRANCISCO SAN JOAQUIN SAN LUIS OBISPO SAN MATEO SANTA BARBARA SANTA CLARA SANTA CRUZ SHASTA SIERRA SISKIYOU SOLANO SONOMA STANISLAUS SUTTER TEHAMA TRINITY TULARE TUOLUMNE VENTURA YOLO YUBA EL PASO FREMONT JEFFERSON PUEBLO County-by-County Coverage Listing FLORIDA ALACHUA BRADFORD BROWARD CHARLOTTE CITRUS CLAY COLLIER COLUMBIA DESOTO DUVAL ESCAMBIA Flagler FRANKLIN GULF HARDEE HENDRY HERNANDO HIGHLANDS HILLSBOROUGH INDIAN RIVER JACKSON LAKE LEE LEON LEVY MANATEE MARION MARTIN MIAMI-DADE OKALOOSA ORANGE OSCEOLA PALM BEACH PASCO PINELLAS POLK SAINT JOHNS SANTA ROSA SARASOTA SEMINOLE SUMTER SUWANNEE VOLUSIA WALTON GEORGIA APPLING BALDWIN BARTOW BIBB BRYAN BUTTS CANDLER CATOOSA CHATHAM CHATTAHOOCHEE CHEROKEE CLAYTON COBB COFFEE COLQUIT COLUMBIA CRAWFORD DADE DEKALB DOUGLAS EARLY EFFINGHAM EMANUEL EVANS FAYETTE FORSYTH FULTON GWINNETT HARRIS HENRY JEFF DAVIS JONES LAURENS LIBERTY GEORGIA (CONT.) LONG MERIWETHER MILLER MONROE MONTGOMERY MORGAN MUSCOGEE NEWTON PAULDING PEACH PIKE RICHMOND ROCKDALE SCHLEY SPALDING STEWART TALBOT TATTNALL TOOMBS TWIGGS WALKER WALTON WARREN WASHINGTON WAYNE WEBSTER HAWAII (EVERY COUNTY) HAWAII KAUAI HONOLULU MAUI KALAWAO IDAHO ADA ADAMS BANNOCK BENEWAH BINGHAM BLAINE BOISE BONNER BONNEVILLE BOUNDARY CANYON CARIBOU CASSIA CLARK ELMORE FREMONT GEM GOODING JEFFERSON JEROME KOOTENAI LATAH MADISON MINIDOKA NEZ PERCE ONEIDA OWYHEE PAYETTE POWER SHOSHONE TETON TWIN FALLS VALLEY WASHINGTON INDIANA (EVERY COUNTY) ADAMS BARTHOLOMEW ALLEN BENTON County-by-County Coverage Listing INDIANA (CONT.) BLACKFORD BOONE BROWN CARROLL CASS CLARK CLAY CLINTON CRAWFORD DAVIESS DEARBORN DECATUR DEKALB DELAWARE DUBOIS ELKHART FAYETTE FLOYD FOUNTAIN FRANKLIN FULTON GIBSON GRANT GREENE HAMILTON HANCOCK HARRISON HENDRICKS HENRY HOWARD HUNTINGTON JACKSON JASPER JAY JEFFERSON JENNINGS JOHNSON KNOX KOSCIUSKO LAGRANGE LAKE LAPORTE LAWRENCE MADISON MARION MARSHALL MARTIN MIAMI MONROE MONTGOMERY MORGAN NEWTON NOBLE OHIO ORANGE OWEN PARKE PERRY PIKE PORTER POSEY PULASKI PUTNAM RANDOLPH RIPLEY RUSH SAINT JOSEPH SCOTT SHELBY SPENCER STARKE STEUBEN SULLIVAN SWITZERLAND TIPPECANOE TIPTON UNION VANDERBURGH VERMILLION VIGO WABASH WARREN INDIANA (CONT.) WARRICK WASHINGTON WAYNE WELLS WHITE WHITLEY KENTUCKY (EVERY COUNTY) ADAIR FLOYD ALLEN FRANKLIN ANDERSON FULTON BALLARD GALLATIN BARREN GARRAD BATH GRANT BELL GRAVES BOONE GRAYSON BOURBON GREEN BOYD GREENUP BOYLE HANCOCK BRACKEN HARDIN BREATHITT HARLAN BRECKINRIDGE HARRISON BULLITT HART BUTLER HENDERSON CALDWELL HENRY CALLOWAY HICKMAN CAMPBELL HOPKINS CARLISLE JACKSON CARROLL JEFFERSON CARTER JESSAMINE CASEY JOHNSON CHRISTIAN KENTON CLARK KNOTT CLAY KNOX CLINTON LARUE CRITTENDEN LAUREL CUMBERLAND LAWRENCE DAVIESS LEE EDMONSON LESLIE ELLIOT LETCHER ESTILL LEWIS FAYETTE LINCOLN FLEMING LIVINGSTON County-by-County Coverage Listing KENTUCKY (CONT.) LOGAN LYON MADISON MAGOFFIN MARION MARSHALL MARTIN MASON MCCRACKEN MCCREARY MCLEAN MEADE MENIFEE MERCER METCALFE MONROE MONTGOMERY MORGAN MUHLENBERG NELSON NICHOLAS OHIO OLDHAM OWEN OWSLEY PENDLETON PERRY PIKE POWELL PULASKI ROBERTSON ROCKCASTLE ROWAN RUSSELL SCOTT SHELBY SIMPSON SPENCER TAYLOR TODD TRIGG TRIMBLE UNION WARREN WASHINGTON WAYNE WEBSTER WHITLEY WOLFE WOODFORD MAINE (EVERY COUNTY) ANDROSCOGGIN OXFORD AROOSTOOK PENOBSCOT CUMBERLAND PISCATAQUIS FRANKLIN SAGADAHOC HANCOCK SOMERSET KENNEBEC WALDO KNOX WASHINGTON LINCOLN YORK MASSACHUSETTS BARNSTABLE BRISTOL ESSEX FRANKLIN HAMPDEN HAMPSHIRE MIDDLESEX NORFOLK MASSACHUSETTS (CONT.) PLYMOUTH WORCESTER SUFFOLK MICHIGAN (EVERY COUNTY) ALCONA ISABELLA ALGER JACKSON ALLEGAN KALAMAZOO ALPENA KALKASKA ANTRIM KENT ARENAC KEWEENAW BARAGA LAKE BARRY LAPEER BAY LEELANAU BENZIE LENAWEE BERRIEN LIVINGSTON BRANCH LUCE CALHOUN MACKINAC CASS MACOMB CHARLEVOIX MANISTEE CHEBOYGAN MARQUETTE CHIPPEWA MASON CLARE MECOSTA CLINTON MENOMINEE CRAWFORD MIDLAND DELTA MISSAUKEE DICKINSON MONROE EATON MONTCALM EMMETT MONTMORENCY GENESEE MUSKEGON GLADWIN NEWAYGO GOGEBIC OAKLAND GRAND TRAVERSE OCEANA GRATIOT OGEMAW HILLSDALE ONTONAGON HOUGHTON OSCEOLA HURON OSCODA INGHAM OTSEGO IONIA OTTAWA IOSCO PRESQUE ISLE IRON ROSCOMMON County-by-County Coverage Listing MICHIGAN (CONT.) SAGINAW SAINT CLAIR SAINT JOSEPH SANILAC SCHOOLCRAFT SHIAWASSEE TUSCOLA VAN BUREN WASHTENAW WAYNE WEXFORD MISSOURI BARRY BARTON CEDAR CHRISTIAN DADE DALLAS DOUGLAS GREENE JASPER LAWRENCE LINCOLN MCDONALD NEWTON OZARK POLK SAINT CHARLES SAINT LOUIS SAINT LOUIS CITY STONE TANEY WARREN WEBSTER WRIGHT NEVADA CLARK NEW HAMPSHIRE CARROLL HILLSBOROUGH WASHOE ROCKINGHAM NEW JERSEY (EVERY COUNTY) ATLANTIC MIDDLESEX BERGEN MONMOUTH BURLINGTON MORRIS CAMDEN OCEAN CAPE MAY PASSAIC CUMBERLAND SALEM ESSEX SOMERSET GLOUCESTER SUSSEX HUDSON UNION HUNTERDON WARREN MERCER NEW YORK (EVERY COUNTY) ALBANY NIAGARA ALLEGANY ONEIDA BRONX ONONDAGA BROOME ONTARIO CATTARAUGUS ORANGE CAYUGA ORLEANS CHAUTAUQUA OSWEGO CHEMUNG OTSEGO CHENANGO PUTNAM CLINTON QUEENS COLUMBIA RENSSELAER CORTLAND RICHMOND DELAWARE ROCKLAND DUTCHESS SAINT LAWRENCE ERIE SARATOGA ESSEX SCHENECTADY FRANKLIN SCHOHARIE FULTON SCHUYLER GENESEE SENECA GREENE STEUBEN HAMILTON SUFFOLK HERKIMER SULLIVAN JEFFERSON TIOGA KINGS TOMPKINS LEWIS ULSTER LIVINGSTON WARREN MADISON WASHINGTON MONROE WAYNE MONTGOMERY WESTCHESTER NASSAU WYOMING NEW YORK YATES NORTH CAROLINA ALAMANCE ALEXANDER ALLEGHANY ANSON ASHE AVERY BEAUFORT BERTIE BLADEN BRUNSWICK CABARRUS CALDWELL CARTERET CASWELL County-by-County Coverage Listing NORTH CAROLINA (CONT.) CATAWBA MITCHELL CHATHAM MONTGOMERY CHOWAN NASH CLEVELAND NEW HANOVER COLUMBUS NORTHAMPTON CUMBERLAND ONSLOW DAVIDSON ORANGE DAVIE PAMLICO DUPLIN PENDER DURHAM PERQUIMANS EDGECOMBE PERSON FORSYTH PITT FRANKLIN POLK GASTON RANDOLPH GATES RICHMOND GRANVILLE ROBESON GREENE ROCKINGHAM GUILFORD ROWAN HALIFAX SAMPSON HARNETT SCOTLAND HAYWOOD STANLY HENDERSON STOKES HERTFORD SURRY HOKE TYRRELL HYDE UNION IREDELL VANCE JOHNSTON WAKE JONES WARREN LEE WASHINGTON LINCOLN WATAUGA MADISON WAYNE MARTIN WILKES MCDOWELL WILSON MECKLENBURG YADKIN OHIO (EVERY COUNTY) ADAMS ALLEN ASHLAND ASHTABULA ATHENS AUGLAIZE BELMONT BROWN OHIO (CONT.) BUTLER CARROLL CHAMPAIGN CLARK CLERMONT CLINTON COLUMBIANA COSHOCTON CRAWFORD CUYAHOGA DARKE DEFIANCE DELAWARE ERIE FAIRFIELD FAYETTE FRANKLIN FULTON GALLIA GEAUGA GREENE GUERNSEY HAMILTON HANCOCK HARDIN HARRISON HENRY HIGHLAND HOCKING HOLMES HURON JACKSON JEFFERSON KNOX LAKE LAWRENCE LICKING LOGAN LORAIN LUCAS MADISON MAHONING MARION MEDINA MEIGS MERCER MIAMI MONROE MONTGOMERY MORGAN MORROW MUSKINGUM NOBLE OTTAWA PAULDING PERRY PICKAWAY PIKE PORTAGE PREBLE PUTNAM RICHLAND ROSS SANDUSKY SCIOT SENECA SHELBY STARK SUMMIT TRUMBULL TUSCARAWAS UNION VAN WERT VINTON WARREN WASHINGTON WAYNE WILLIAMS WOOD WYANDOT County-by-County Coverage Listing OREGON BENTON CLACKAMAS CLATSOP COLUMBIA COOS CURRY DOUGLAS HOOD RIVER JACKSON JOSEPHINE LANE LINCOLN LINN MARION MULTNOMAH POLK TILLAMOOK WASCO WASHINGTON YAMHILL PENNSYLVANIA (EVERY COUNTY) ADAMS GREENE ALLEGHENY HUNTINGDON ARMSTRONG INDIANA BEAVER JEFFERSON BEDFORD JUNIATA BERKS LACKAWANNA BLAIR LANCASTER BRADFORD LAWRENCE BUCKS LEBANON BUTLER LEHIGH CAMBRIA LUZERNE CAMERON LYCOMING CARBON MCKEAN CENTRE MERCER CHESTER MIFFLIN CLARION MONROE CLEARFIELD MONTGOMERY CLINTON MONTOUR COLUMBIA NORTHAMPTON CRAWFORD NORTHUMBERLAND CUMBERLAND PERRY DAUPHIN PHILADELPHIA DELAWARE PIKE ELK POTTER ERIE SCHUYLKILL FAYETTE SNYDER FOREST SOMERSET FRANKLIN SULLIVAN FULTON SUSQUEHANNA PENNSYLVANIA (CONT.) TIOGA WAYNE UNION WESTMORELAND VENANGO WYOMING WARREN YORK WASHINGTON PUERTO RICO (EVERY COUNTY) ADJUNTAS HATILLO AGUADA HORMIGUEROS AGUADILLA HUMACAO AGUAS BUENAS ISABELA AIBONITO JAYUYA ANASCO JUANA DIAZ ARECIBO JUNCOS ARROYO LAJAS BARCELONETA LARES BARRANQUITAS LAS MARIAS BAYAMON LAS PIEDRAS CABO ROJO LOIZA CAGUAS LUQUILLO CAMUY MANATI CANOVANAS MARICAO CAROLINA MAUNABO CATANO MAYAGUEZ CAYEY MOCA CEIBA MOROVIS CIALES NAGUABO CIDRA NARANJITO COAMO OROCOVIS COMERIO PATILLAS COROZAL PENUELAS CULEBRA PONCE DORADO QUEBRADILLAS FAJARDO RINCON FLORIDA RIO GRANDE GUANICA SABANA GRANDE GUAYAMA SALINAS GUAYANILLA SAN GERMAN GUAYNABO SAN JUAN GURABO SAN LORENZO County-by-County Coverage Listing PUERTO RICO (CONT.) SAN SEBASTIAN SANTA ISABEL TOA ALTA TOA BAJA TRUJILLO ALTO UTUADO VEGA ALTA VEGA BAJA VIEQUES VILLALBA YABUCOA YAUCO SOUTH CAROLINA (EVERY COUNTY) ABBEVILLE GREENWOOD AIKEN HAMPTON ALLENDALE HORRY ANDERSON JASPER BAMBERG KERSHAW BARNWELL LANCASTER BEAUFORT LAURENS BERKELEY LEE CALHOUN LEXINGTON CHARLESTON MARION CHEROKEE MARLBORO CHESTER MCCORMICK CHESTERFIELD NEWBERRY CLARENDON OCONEE COLLETON ORANGEBURG DARLINGTON PICKENS DILLON RICHLAND DORCHESTER SALUDA EDGEFIELD SPARTANBURG FAIRFIELD SUMTER FLORENCE UNION GEORGETOWN WILLIAMSBURG GREENVILLE YORK TENNESSEE (EVERY COUNTY) ANDERSON CARROLL BEDFORD CARTER BENTON CHEATHAM BLEDSOE CHESTER BLOUNT CLAIBORNE BRADLEY CLAY CAMPBELL COCKE CANNON COFFEE TENNESSEE (CONT.) CROCKETT CUMBERLAND DAVIDSON DECATUR DEKALB DICKSON DYER FAYETTE FENTRESS FRANKLIN GIBSON GILES GRAINGER GREENE GRUNDY HAMBLEN HAMILTON HANCOCK HARDEMAN HARDIN HAWKINS HAYWOOD HENDERSON HENRY HICKMAN HOUSTON HUMPHREYS JACKSON JEFFERSON JOHNSON KNOX LAKE LAUDERDALE LAWRENCE LEWIS LINCOLN LOUDON MACON MADISON MARION MARSHALL MAURY MCMINN MCNAIRY MEIGS MONROE MONTGOMERY MOORE MORGAN OBION OVERTON PERRY PICKETT POLK PUTNAM RHEA ROANE ROBERTSON RUTHERFORD SCOTT SEQUATCHIE SEVIER SHELBY SMITH STEWART SULLIVAN SUMNER TIPTON TROUSDALE UNICOI UNION VAN BUREN WARREN WASHINGTON WAYNE WEAKLEY WHITE WILLIAMSON WILSON County-by-County Coverage Listing TEXAS BASTROP BURNET CALDWELL COLLIN DALLAS DENTON FAYETTE FORT BEND HARRIS HAYS LEE MONTGOMERY TARRANT TRAVIS WILLIAMSON UTAH BOX CACHE DAVIS IRON MORGAN RICH SALT LAKE SUMMIT TOOELE UTAH WASATCH WASHINGTON WEBER VIRGINIA ALBEMARLE AMELIA APPOMATTOX BEDFORD BEDFORD CITY BOTETOURT BUENA VISTA CITY CAROLINE CHARLES CITY CHARLOTTE CHARLOTTESVILLE CITY CHESAPEAKE CITY CHESTERFIELD COL. HEIGHTS CITY CRAIG CULPEPER CUMBERLAND DINWIDDIE EMPORIA CITY FLOYD FLUVANNA FRANKLIN GILES GLOUCESTER GOOCHLAND GREENSVILLE HAMPTON CITY HANOVER HENRICO HOPEWELL CITY JAMES CITY KING AND QUEEN LANCASTER LEXINGTON CITY LOUISA LUNENBURG MADISON MATHEWS MIDDLESEX MONTGOMERY NEW KENT NEWPORT NEWS CITY VIRGINIA (CONT.) NORFOLK CITY NORTHAMPTON NORTHUMBERLAND ORANGE PAGE PETERSBURG CITY POQUOSON CITY PORTSMOUTH CITY POWHATAN PRINCE GEORGE PULASKI RADFORD RICHMOND WASHINGTON ASOTIN CLALLAM CLARK COLUMBIA COWLITZ ISLAND KING KITSAP KLICKITAT LEWIS RICHMOND CITY ROANOKE ROANOKE CITY ROCKBRIDGE SALEM SHENANDOAH SUFFOLK SURRY VIRGINIA BEACH CITY WARREN WILLIAMSBURG CITY YORK PIERCE SAN JUAN SKAGIT SKAMANIA SNOHOMISH THURSTON WAHKIAKUM WALLA WALLA WHATCOM YAKIMA WEST VIRGINIA (EVERY COUNTY) BARBOUR HANCOCK BERKELEY HARDY BOONE HARRISON BRAXTON JACKSON BROOKE JEFFERSON CABELL KANAWHA CALHOUN LEWIS CLAY LINCOLN DODDRIDGE LOGAN FAYETTE MARION GILMER MARSHALL GRANT MASON GREENBRIER MCDOWELL HAMPSHIRE MERCER County-by-County Coverage Listing WEST VIRGINIA (CONT.) MINERAL MINGO MONONGALIA MONROE MORGAN NICHOLAS OHIO PENDLETON PLEASANTS POCAHONTAS PRESTON PUTNAM RALEIGH RANDOLPH WISCONSIN BROWN CALUMET COLUMBIA DODGE FOND DU LAC GREEN LAKE JEFFERSON KENOSHA MANITOWOC MARATHON MARINETTE MILWAUKEE OCONTO RITCHIE ROANE SUMMERS TAYLOR TUCKER TYLER UPSHUR WAYNE WEBSTER WETZEL WIRT WOOD WYOMING OUTAGAMIE OZAUKEE PORTAGE RACINE ROCK SHAWANO SHEBOYGAN WALWORTH WASHINGTON WAUKESHA WAUPACA WAUSHARA WINNEBAGO County-by-County Coverage Listing The Visitor/Travel Program will include Blue Medicare Advantage PPO network coverage of all Part A, Part B, and Supplemental benefits offered by your plan outside your service area in 31 states and 1 territory: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, North Carolina, New York, Ohio, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin. For some of the states listed, MA PPO networks are only available in portions of the state. Y Highmark our Coverage Go-To Guide 2189DP As a Highmark member, you have the same in-network benefits and low costs at home and across the country. Whether you’re heading where it’s warm for the winter or just taking a weekend trip, you’ll receive in-network level benefits in all counties listed in this booklet. Wherever you go, it’s easy to find a provider. Go online to the “Doctor and Hospital Finder” at http://provider.bcbs.com and follow the simple search instructions. Under Medicare Advantage rules, if you are absent from the service area for more than six (6) months, you must be disenrolled. However, in areas where we offer the Visitor/Travel Program you may remain in the plan while out of our service area for 6 months. Members who see Medicare Advantage PPO providers in any geographic area where the Visitor/Travel Program is offered will pay the same cost-sharing level (innetwork cost-sharing) they would pay if they received covered benefits from in-network providers in their service area. Highmark, Inc. is a Health plan with a Medicare contract. Highmark Health Insurance Company is a Health plan with a Medicare contract. Highmark is a registered mark of Highmark Inc. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Highmark Health Insurance Company is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Freedom Blue is a service mark of the Blue Cross and Blue Shield Association. Stay in network — even when you’re out of town. If you’re enrolled in a Highmark Medicare Advantage PPO plan, you can call Member Service using the phone number that’s printed on the back of your Freedom Blue PPO Member ID card. If you have your enrollment forms and are thinking about becoming a member, you can find nationwide providers by calling the phone or TTY number listed on your enrollment materials. In-network coverage from coast to coast Coverage at home: • Access to participating doctors and hospitals wherever you go in Pennsylvania, West Virginia, New York, Ohio and New Jersey. • More choice through one of the largest Medicare Advantage PPO networks in the state. • Over 34,000 doctors, specialists and hospitals in Pennsylvania and West Virginia. • High standards of quality — Every participating Freedom Blue PPO provider is carefully screened before admission to the network. Then each is reviewed regularly to ensure you continue to receive the highest quality of care. Coverage when you travel: • The same level of care and coverage nationwide from any participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider or hospital. • Coverage in 31 states and 1 territory, including Florida, California, the Carolinas, New York, Texas, Puerto Rico and more. The highest level of emergency benefits — anywhere No matter where you are, emergency and urgent care are always covered at the highest level of coverage. H3916_H5106_12_0576 Accepted
