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Freedom Blue PPO Select (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$139.00
Monthly Premium
Freedom Blue PPO Select (PPO) is a PPO plan offered by Highmark Health
Plan ID: H3916-022
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Freedom Blue PPO Select (PPO) - H3916-022 by Highmark Health as well as other Medicare Advantage plans available in your area.
$139.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5000 Out-of-Network: 8950 |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30 |
| Inpatient Hospital Care | Out-of-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $350 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 $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $50 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $130 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation $300 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300 Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. Air Ambulance: Copayment for Air Ambulance Services $300 Prior Authorization Required for Air Ambulance Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. |
Health Care Services and Medical Supplies
Freedom Blue PPO Select (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 | Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15 In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
|
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: 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. |
| Durable Medical Equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 30% |
| 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 to $15 Copayment for Medicare-covered Lab Services $0 to $15 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services The minimum copayment applies for Medicare-covered diagnostic procedures/tests and lab services provided at free standing labs. The maximum copayment applies for Medicare-covered diagnostic procedures/tests and lab services at all other places of service. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $125 Copayment for Medicare-covered Therapeutic Radiological Services $60 Copayment for Medicare-covered X-Ray Services $20 |
| Home Health Care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 30% |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital per Stay $350 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 Care | Out-of-Network: Mental Health Services: Copayment for Medicare Covered Individual Sessions $30 Copayment for Medicare Covered Group Sessions $30 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $175 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 $175 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 $125 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 Care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $30 Copayment for Medicare Covered Group Sessions $30 |
| Over-the-counter (OTC) Items | |
| Podiatry Services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $30 In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30 Copayment for Routine Foot Care $30
|
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Private accommodations will be covered when medically necessary. |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network:
Copayment for Dental x-rays $0
Copayment for Prophylaxis $0
Please see Evidence of Coverage for details |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Out-of-Network: Eye Exams Services: Copayment for Medicare Covered Eye Exams $30 Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Out-of-Network: Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $30 |
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 | Out-of-Network: Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |