Freedom Blue PPO Standard (PPO)

3.5 out of 5 stars

^$134.00

Monthly Premium

Freedom Blue PPO Standard (PPO) is a PPO plan offered by Highmark Health

Plan ID: H5106-034

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) - H5106-034 by Highmark Health as well as other Medicare Advantage plans available in your area.

^$134.00

Monthly Premium

West Virginia Counties Served

Beaver Berkeley Braxton Brooke Cabell Clay Doddridge Fayette Frederick Greenbrier Hardy Harrison Jefferson Kanawha Lincoln Marion Marshall Mason Mcdowell Mercer Mingo Nicholas Ohio Putnam Raleigh Randolph Wayne Wood

Basic Costs and Coverage

Coverage	Cost
Monthly Deductible	$0
Out of Pocket Max	In-Network: $6500 Out-of-Network: 10000
Initial Coverage Limit	$0
Catastrophic Coverage Limit	$2100
Primary Care Doctor Visit	Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered 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: $150 per day for days 1 to 7 $0 per day for days 8 to 90 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 $330
Ambulance Transportation	Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $330 Coinsurance for Medicare Covered Ambulance Services - Ground $30% Copayment for Medicare Covered Ambulance Services - Air $330 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	In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15 Maximum 8 Routine Care every year Prior Authorization Required for Chiropractic Services Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15
Diabetes Supplies, Training, Nutrition Therapy and Monitoring	In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% 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 .Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to Abbott and Trivida. Continuous glucose monitors, sensors and transmitters dispensed via retail or mail order pharmacy are limited to Abbott and Dexcom. All other desired brands will need to be obtained via an exception process or from a Durable Medical Equipment (DME) supplier.
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 $10 Copayment for Medicare-covered Lab Services $0 to $10 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 $75 Copayment for Medicare-covered Therapeutic Radiological Services $60 Copayment for Medicare-covered X-Ray Services $25
Home Health Care	Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care	In-Network: Psychiatric Hospital Services: $150 per day for days 1 to 7 $0 per day for days 8 to 90 Prior Authorization Required for Psychiatric Hospital Services 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 $35 Copayment for Medicare Covered Group Sessions $35
Outpatient Services / Surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $150 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 $150 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 $100 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	Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $35 Copayment for Medicare Covered Group Sessions $35 In-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	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35 Copayment for Routine Foot Care $35 Maximum 10 visits every year Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $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	Out-of-Network: Dental Services: Copayment for Medicare Covered Dental $35 Preventive Dental Services: Coinsurance for Covered Preventive Dental 30% Comprehensive Dental Services: Coinsurance for Covered Comprehensive Dental services 30% 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 $35

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 $35 Copayment for Routine Hearing Exams $0 Maximum 1 visit every year Hearing Aids: Copayment for Hearing Aids $399 to $699 Maximum 2 Hearing Aids every year Maximum Plan Benefit of $500 every year for any other hearing aid. Members must use our contracted provider to use this benefit. Up to two hearing aids every year (one per ear per year). Benefit is limited to the Advanced (minimum cost sharing) and Premium (maximum cost sharing) hearing aids, which come in various styles and colors, and are available in rechargeable style options at no additional charge.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 modelsBenefit does not include or cover any of the following:• Additional cost for optional hearing aid rechargeability • Ear molds• Hearing aid accessories• Additional provider visits• Additional batteries - batteries when a rechargeable hearing aid is purchased• Hearing aids that are not TruHearing-branded hearing aids• Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan.Services not covered under any condition:Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), ear molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the 80 free batteries per non-rechargeable aid purchased).Members have a $500 maximum allowance towards hearing aids that are not the Advanced or Premium models.

Coverage

Cost

Hearing Benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35
Copayment for Routine Hearing Exams $0

Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $399 to $699

Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $500 every year for any other hearing aid.
Members must use our contracted provider to use this benefit. Up to two hearing aids every year (one per ear per year). Benefit is limited to the Advanced (minimum cost sharing) and Premium (maximum cost sharing) hearing aids, which come in various styles and colors, and are available in rechargeable style options at no additional charge.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 modelsBenefit does not include or cover any of the following:• Additional cost for optional hearing aid rechargeability • Ear molds• Hearing aid accessories• Additional provider visits• Additional batteries - batteries when a rechargeable hearing aid is purchased• Hearing aids that are not TruHearing-branded hearing aids• Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan.Services not covered under any condition:Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), ear molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the 80 free batteries per non-rechargeable aid purchased).Members have a $500 maximum allowance towards hearing aids that are not the Advanced or Premium models.

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

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