Freedom Basic (PPO)
Freedom Basic (PPO) H5526-022 Plan Details
Freedom Basic (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5526-022
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$0.00
Monthly Premium
Freedom Basic (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5526-022
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
New York Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $350 |
| Out of Pocket Max |
In-Network: $8300 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 to $10.00 Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 50% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 50% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $400.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Maximum out of Pocket $2000.00 every year Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Coinsurance for Acute Hospital Services per Stay 50% |
| Urgent Care | Copayment for Urgent Care $55.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $55.00 |
| Emergency Room Visit | Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $305.00 Air Ambulance: Copayment for Air Ambulance Services $305.00 Prior authorization required for air/water ambulance. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $305.00 Copayment for Medicare Covered Ambulance Services - Air $305.00 |
Health Care Services and Medical Supplies
Freedom Basic (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $15.00 Copayment for Routine Care $15.00
Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 50% Coinsurance for Non-Medicare Covered Chiropractic Services 50% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 50% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 50% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $50.00 Copayment for Medicare-covered Lab Services $10.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $200.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $50.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50% Copayment for Medicare Covered Lab Services $10.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Coinsurance for Medicare Covered Outpatient X-Ray Services 50% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Out-of-Network: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $395.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Maximum out of Pocket $1580.00 every year Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 50% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $475.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $475.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $425.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Copayment for Routine Foot Care $40.00
Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 50% Coinsurance for Non-Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 50% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Office Visit: $20.00 including: • Oral Exams Maximum 2 per year • Prophylaxis (Cleaning) Maximum 2 per year
• Dental X-Rays Maximum 1 visit every year Medicare Covered Dental Services: Copayment for Medicare-covered Benefits $40.00 Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Comprehensive Dental $20.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 50% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $40.00 Copayment for Routine Eye Exams $25.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 50% Coinsurance for Medicare Covered Eyewear 20% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 20% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40.00 Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 50% |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% |
Prescription Drug Costs and Coverage
The Freedom Basic (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $350 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $350 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $350 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $350 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
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