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Freedom Blue PPO Standard (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.
$121.00
Monthly Premium
Freedom Blue PPO Standard (PPO) is a PPO plan offered by Highmark Health
Plan ID: H3916-015
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 Standard (PPO) - H3916-015 by Highmark Health as well as other Medicare Advantage plans available in your area.
$121.00
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 $35 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $475 Prior Authorization Required for Acute Hospital Services 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 $260 |
| Ambulance Transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $260 Coinsurance for Medicare Covered Ambulance Services - Ground $30% Copayment for Medicare Covered Ambulance Services - Air $260 Coinsurance for Medicare Covered Ambulance Services - Air $30% 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 Standard (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 | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Diabetic Supplies 30% Coinsurance for Diabetic Therapeutic Shoes or Inserts 30% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| 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 $475 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 | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $200 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 $200 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 $150 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 $35 Copayment for Medicare-covered Group Sessions $35 Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $35 Copayment for Medicare Covered Group Sessions $35 |
| Over-the-counter (OTC) Items | |
| Podiatry Services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $35 In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35 Copayment for Routine Foot Care $35
|
| 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 | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $35 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0 Copayment for Eyeglass Lenses $0 Copayment for Eyeglass Frames $0 Copayment for Upgrades $0 Maximum Plan Benefit of $425 every year A $200 benefit maximum applies to upgrades to post cataract surgery eyewear that are not medically necessary. Benefit maximum is available following cataract surgery once per operated eye. For non-post cataract eyewear, the Plan offers additional coverage for non-Medicare covered (routine) eyewear. Routine eyewear benefit is limited to one pair of eyeglass frames, including one pair of eyeglass lenses or contact lenses every calendar year. Standard eyeglass frames, standard plastic eyeglass lenses, or standard contact lenses are covered in full at participating network provider locations. A $225 benefit maximum is available towards the purchase of non-standard eyeglass frames or towards the purchase of non-standard contact lenses. Members must pay the difference between benefit maximums and provider charge. |
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 $35 |
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 |