Freedom Blue PPO Signature (PPO)
Freedom Blue PPO Signature (PPO) H5106-030 Plan Details
Freedom Blue PPO Signature (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5106-030
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$0.00
Monthly Premium
Freedom Blue PPO Signature (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5106-030
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
West Virginia Counties Served
Calhoun
Beaver
Tyler
Marshall
Jefferson
Ohio
Tucker
Mineral
Barbour
Wood
Wetzel
Taylor
Hancock
Grant
Lewis
Pendleton
Ritchie
Pleasants
Wirt
Marion
Berkeley
Brooke
Gilmer
Randolph
Preston
Upshur
Hampshire
Monongalia
Doddridge
Morgan
Harrison
Hardy
Pocahontas
Roane
Mason
Monroe
Kanawha
Boone
Lincoln
Summers
Mingo
Putnam
Mercer
Wayne
Jackson
Cabell
Greenbrier
Fayette
Raleigh
Logan
Nicholas
Mcdowell
Clay
Wyoming
Webster
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $7550 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 $25.00 Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $25.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $250.00 per day for days 1 to 3 $0.00 per day for days 4 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: $425.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
| Urgent Care | Copayment for Urgent Care $35.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $35.00 |
| 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 $250.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $250.00 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 $250.00 Coinsurance for Medicare Covered Ambulance Services - Ground 30% Copayment for Medicare Covered Ambulance Services - Air $250.00 Coinsurance for Medicare Covered Ambulance Services - Air 30% |
Health Care Services and Medical Supplies
Freedom Blue PPO Signature (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
Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $40.00 Copayment for Non-Medicare Covered Chiropractic Services $40.00 |
| 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 Prior authorization required Out-of-Network: 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 $0.00 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 $250.00 Copayment for Medicare-covered Therapeutic Radiological Services $60.00 Copayment for Medicare-covered X-Ray Services $25.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $20.00 Copayment for Medicare Covered Lab Services $20.00 Copayment for Medicare Covered Diagnostic Radiological Services $350.00 Copayment for Medicare Covered Therapeutic Radiological Services $75.00 Copayment for Medicare Covered Outpatient X-Ray Services $40.00 |
| 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: $425.00 per day for days 1 to 3 $0.00 per day for days 4 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: $500.00 per day for days 1 to 3 $0.00 per day for days 4 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual Sessions $50.00 Copayment for Medicare Covered Group Sessions $50.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $300.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $250.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $350.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $350.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $50.00 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $85.00 every three months Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $85.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $25.00 Copayment for Routine Foot Care $25.00
Out-of-Network: Copayment for Medicare Covered Podiatry Services $25.00 Copayment for Non-Medicare Covered Podiatry Services $25.00 |
| 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 | Preventive Dental: Copayment for Office Visit: $0 including: • Oral Exams Maximum 1 visit every six months • Prophylaxis (Cleaning) Maximum 1 visit every six months • Fluoride Maximum 1 visit every six months • Dental X-Rays Maximum 1 visit every year Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Comprehensive Dental 20% Medicare Covered Dental Services: Copayment for Medicare-covered Benefits $25.00 Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $25.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 30% Coinsurance for Non-Medicare Covered Comprehensive Dental 50% Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Prior Authorization Required for Comprehensive Dental Prior authorization required |
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 $25.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Standard Eyeglass lenses and frames or contact lenses are covered in full. IN/OON: A $100 benefit maximum applies to non-standard frames and a $100 benefit maximum for specialty contact lenses. $200 benefit maximum for post cataract eyewear Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $25.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $50.00 Standard Eyeglass lenses and frames or contact lenses are covered in full. IN/OON: A $100 benefit maximum applies to non-standard frames and a $100 benefit maximum for specialty contact lenses. $200 benefit maximum for post cataract eyewear |
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 $25.00 Copayment for Routine Hearing Exams $25.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
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 ($699) and Premium ($999) 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 $25.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $25.00 Copayment for Non-Medicare Covered Hearing Aids $0.00 |
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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