Freedom Blue PPO Standard (PPO)
Freedom Blue PPO Standard (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-015-000
Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $164.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,000.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35.00 |
| Inpatient hospital care | Out-of-Network: Copayment for Acute Hospital Services per Stay $475.00 |
| Urgent care | Urgent Care: Copayment for Urgent Care $5.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $5.00 |
| Emergency room visit | Emergency Care: 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 $215.00 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $215.00 Coinsurance for Medicare Covered Ambulance Services - Ground 30% Copayment for Medicare Covered Ambulance Services - Air $215.00 Coinsurance for Medicare Covered Ambulance Services - Air 30% |
Health Care Services and Medical Supplies
Freedom Blue PPO Standard (PPO) covers a range of additional benefits. Learn more about Freedom Blue PPO Standard (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $20.00 Chiropractic Services: Copayment for Non-Medicare Covered Chiropractic Services $20.00 |
| 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% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
| 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 | Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $15.00 Copayment for Medicare Covered Lab Services $15.00 Copayment for Medicare Covered Diagnostic Radiological Services $125.00 Copayment for Medicare Covered Therapeutic Radiological Services $60.00 Copayment for Medicare Covered Outpatient X-Ray Services $20.00 |
| 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: Copayment for Psychiatric Hospital Services per Stay $475.00 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $35.00 Copayment for Medicare Covered Group Sessions $35.00 |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $200.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $150.00 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $35.00 Copayment for Medicare-covered Group Sessions $35.00 Prior Authorization Required for Outpatient Substance Abuse Services |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $35.00 Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $35.00 |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 30% |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Preventive Dental: Copayment for Office Visit $15.00 including: Oral Exams
Prophylaxis (Cleaning)
Dental X-Rays
Comprehensive Dental: Copayment for Medicare-covered Benefits $35.00 Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $35.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 30% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $35.00 Copayment for Routine Eye Exams $0.00
Eyewear: A $175 benefit maximum applies to non-standard frames or specialty contact lenses. Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $35.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $50.00 A $175 benefit maximum applies to non-standard frames or specialty contact lenses. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing benefits | Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $35.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $35.00 Copayment for Non-Medicare Covered Hearing Aids $0.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
