Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5106-013-000
Plan Organization Highmark Inc.
Plan Type Local PPO
Plan Name Freedom Blue PPO Standard (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $167.00
Total Premium (Includes Part B) $302.50
Monthly Part C Premium $89.80
Monthly Part D Basic Premium $77.20
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $77.20
Monthly Part D Premium Full Assistance $39.70
Monthly Part D Premium 75% Assistance $49.10
Monthly Part D Premium 50% Assistance $58.50
Monthly Part D Premium 25% Assistance $67.80
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6500.00
Gap Coverage No

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No $100 copay
Diagnostic tests and procedures - Out-of-Network Yes No $10 copay
Lab services - Out-of-Network Yes No $10 copay
Outpatient x-rays - Out-of-Network Yes No $25 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $0 copay
Specialist - Out-of-Network No No $35 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $50 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No $35 copay
Routine foot care Yes Out-of-Network No No $35 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $225 copay or 30% coinsurance
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids Yes Out-of-Network No No $0 copay
Hearing exam - Out-of-Network No No $35 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $150 per day for days 1 through 7$0 per day for days 8 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network$6,500 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 30% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 30% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 30% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 30% coinsurance
Other Part B drugs - Out-of-Network Yes - 30% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $150 per day for days 1 through 7$0 per day for days 8 through 90
Outpatient group therapy visit - Out-of-Network Yes No $35 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $35 copay
Outpatient individual therapy visit - Out-of-Network Yes No $35 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No $35 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $200 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No Covered under office visit
Dental x-ray(s) Yes Out-of-Network No No 30% coinsurance
Fluoride treatment No - - - Not covered
Office visit - Out-of-Network No No 30% coinsurance
Oral exam Yes - No No Covered under office visit
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No $35 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $35 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 30% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes Out-of-Network Yes No 30% coinsurance
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network No No $0 copay
Eyeglass frames Yes Out-of-Network No No $0 copay
Eyeglass lenses Yes Out-of-Network No No $0 copay
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam Yes Out-of-Network No No $50 copay
Upgrades Yes Out-of-Network No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.