Vermont Blue Advantage Freedom Plus PPO (PPO) H6898-002-000 is a 2021 Medicare Advantage plan with drug coverage provided by Vermont Blue Advantage.

In terms of networks, this plan is a Local PPO. With a PPO, you don’t need to choose a primary care doctor and can utilize healthcare providers inside or outside your network (although you'll typically pay less for providers in a plan's network). Local PPOs cover only a small service area, such as a part of a county, a single county, or a group of counties. If you need a wider area of coverage, you may want to look at Regional PPO plans if any are available in your region.

When it comes to cost-sharing, you’ll want to consider both monthly costs and out-of-pocket costs. This plan has a monthly premium of $59, which covers both the health and drug portions of the plan.

The drug plan portion of this plan provides Enhanced Alternative (EA) benefits, which are benefits that exceed the required standard.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $150.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H6898-002-000
Plan Organization Vermont Blue Advantage
Plan Type Local PPO
Plan Name Vermont Blue Advantage Freedom Plus PPO (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $59.00
Total Premium (Includes Part B) $194.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $59.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $59.00
Monthly Part D Premium Full Assistance $23.80
Monthly Part D Premium 75% Assistance $32.60
Monthly Part D Premium 50% Assistance $41.40
Monthly Part D Premium 25% Assistance $50.20
Part D Drug Deductible $150.00
Annual Drug Deductible $150.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5000.00
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 - - Yes, contact plan for further details
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes Out-of-Network No No 50% coinsurance
Endodontics Yes Out-of-Network No No 50% coinsurance
Extractions Yes Out-of-Network No No 50% coinsurance
Non-routine services No - - - Not covered
Periodontics Yes Out-of-Network No No 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network No No 50% coinsurance
Restorative services Yes Out-of-Network No No 50% coinsurance
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network No No $10-200 copay
Diagnostic tests and procedures - Out-of-Network No No $10-200 copay
Lab services - Out-of-Network No No $20 copay
Outpatient x-rays - Out-of-Network No No $10-200 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $25 copay per visit
Specialist - Out-of-Network No No $30 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 - - - - $55 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 $40 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $200 copay
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 Yes Out-of-Network No No $15-40 copay
Hearing aids Yes Out-of-Network No No $0 copay
Hearing exam - Out-of-Network No No $15-40 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $350 per day for days 1 through 4$0 per day for days 5 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,000 In and Out-of-network$5,000 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network No - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network No - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20-35% coinsurance
Other Part B drugs - Out-of-Network Yes - 20-35% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network No No $350 per day for days 1 through 4$0 per day for days 5 through 90
Outpatient group therapy visit - Out-of-Network No No $30 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No $40 copay
Outpatient individual therapy visit - Out-of-Network No No $30 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No $40 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 Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment Yes Out-of-Network No No $0 copay
Oral exam Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network No No $30 copay
Physical therapy and speech and language therapy visit - Out-of-Network No No $40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $0 per day for days 1 through 20$160 per day for days 21 through 48$0 per day for days 49 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network No No 40% coinsurance
Eyeglass frames Yes Out-of-Network No No 40% coinsurance
Eyeglass lenses Yes Out-of-Network No No 40% coinsurance
Eyeglasses (frames and lenses) Yes Out-of-Network No No 40% coinsurance
Other No - - - Not covered
Routine eye exam Yes Out-of-Network No No $40 copay
Upgrades - - - - Not covered
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

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