Freedom Blue PPO Deluxe (PPO)
Freedom Blue PPO Deluxe (PPO) H3916-005 Plan Details
Freedom Blue PPO Deluxe (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-005
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$278.00
Monthly Premium
Freedom Blue PPO Deluxe (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-005
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Pennsylvania Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4500 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 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30.00 Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $30.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $235.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Copayment for Acute Hospital Services per Stay $235.00 |
| Urgent Care | Copayment for Urgent Care $5.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $5.00 |
| Emergency Room Visit | Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $140.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $140.00 Air Ambulance: Copayment for Air Ambulance Services $140.00 Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $140.00 Coinsurance for Medicare Covered Ambulance Services - Ground 30% Copayment for Medicare Covered Ambulance Services - Air $140.00 Coinsurance for Medicare Covered Ambulance Services - Air 30% |
Health Care Services and Medical Supplies
Freedom Blue PPO Deluxe (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 $20.00 Copayment for Routine Care $20.00
Out-of-Network: Copayment for Medicare Covered Chiropractic Services $20.00 Copayment for Non-Medicare Covered Chiropractic Services $20.00 Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% 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 30% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 30% Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $10.00 Copayment for Medicare-covered Lab Services $0.00 to $10.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $60.00 Copayment for Medicare-covered Therapeutic Radiological Services $60.00 Copayment for Medicare-covered X-Ray Services $10.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $10.00 Copayment for Medicare Covered Lab Services $10.00 Copayment for Medicare Covered Diagnostic Radiological Services $75.00 Copayment for Medicare Covered Therapeutic Radiological Services $60.00 Copayment for Medicare Covered Outpatient X-Ray Services $10.00 Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 30% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $235.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $235.00 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 Prior Authorization Required for Outpatient Mental Health Services Out-of-Network: Copayment for Medicare Covered Individual Sessions $30.00 Copayment for Medicare Covered Group Sessions $30.00 Prior authorization required |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $175.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $175.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $100.00 Prior Authorization Required for Ambulatory Surgical Center Services Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $175.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $100.00 Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 Prior Authorization Required for Outpatient Substance Abuse Services Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $30.00 Prior authorization required |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30.00 Copayment for Routine Foot Care $30.00
Out-of-Network: Copayment for Medicare Covered Podiatry Services $30.00 Copayment for Non-Medicare Covered Podiatry Services $30.00 |
| 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 30% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental:
Prophylaxis (Cleaning)
Dental X-Rays
Comprehensive Dental: Copayment for Medicare-covered Benefits $30.00 Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $30.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 30% |
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 $30.00 Copayment for Routine Eye Exams $0.00
Eyewear: A $175 benefit maximum applies to non-standard frames or specialty contact lenses. Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $30.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $50.00 A $175 benefit maximum applies to non-standard frames or specialty contact lenses. |
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 $30.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $399.00 to $699.00
You must see a TruHearing provider to use this benefit. Up to two TruHearing hearing aids every year (one per ear per year). Benefit is limited to the TruHearing Advanced ($399) and Premium ($699) hearing aids, which come in various styles and colors, and are available in rechargeable style options. 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 Members have a $500 maximum allowance towards hearing aids that are not the TruHearing Advanced or Premium models. Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $30.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $30.00 |
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: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
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