Freedom Blue PPO Valor (PPO)

Freedom Blue PPO Valor (PPO) H8166-003 Plan Details
4 out of 5 stars

Freedom Blue PPO Valor (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H8166-003

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$0.00
Monthly Premium

Freedom Blue PPO Valor (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H8166-003

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Freedom Blue PPO Valor (PPO) H8166-003 Plan Details
4 out of 5 stars

Freedom Blue PPO Valor (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H8166-003

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$0.00
Monthly Premium

Delaware Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
Out of Pocket Max In-Network: $6000
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 $10.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $10.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $275.00
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 $395.00
Urgent Care
Copayment for Urgent Care $50.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50.00
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 Valor (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
  • Maximum 8 Routine Care every year
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $35.00 Copayment for Non-Medicare Covered Chiropractic Services $35.00
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
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $225.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $20.00
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 $35.00
Copayment for Medicare Covered Lab Services $35.00
Copayment for Medicare Covered Diagnostic Radiological Services $325.00
Copayment for Medicare Covered Therapeutic Radiological Services $80.00
Copayment for Medicare Covered Outpatient X-Ray Services $35.00
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:
$325.00 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:
$475.00 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 $5.00
Copayment for Medicare-covered Group Sessions $5.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $35.00
Copayment for Medicare Covered Group Sessions $35.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $245.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $245.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $195.00
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 $375.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $325.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $5.00
Copayment for Medicare-covered Group Sessions $5.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $35.00
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 $100.00 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 $100.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $10.00
Copayment for Routine Foot Care $10.00
  • Maximum 10 visits every year
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $10.00 Copayment for Non-Medicare Covered Podiatry Services $10.00
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:
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

Medicare Covered Dental Services:
Copayment for Medicare-covered Benefits $10.00

Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Comprehensive Dental 40%


Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $10.00
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 30%
Coinsurance for Non-Medicare Covered Comprehensive Dental 40%

Maximum Plan Benefit of $3000.00 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 $10.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Standard Eyeglass lenses and frames or contact lenses are covered in full. IN/OON: A $150 benefit maximum applies to non-standard frames and a $150 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 $10.00

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 $150 benefit maximum applies to non-standard frames and a $150 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 $10.00
Copayment for Routine Hearing Exams $10.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year

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 $10.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $10.00

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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00