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Blue Cross Medicare Advantage Freedom Blue (PPO)

H5959 - 008 - 0
4.5 out of 5 stars (4.5 / 5)

Blue Cross Medicare Advantage Freedom Blue (PPO) is a Medicare Advantage (Part C) Plan by Blue Cross and Blue Shield of Minnesota.

This page features plan details for 2023 Blue Cross Medicare Advantage Freedom Blue (PPO) H5959 – 008 – 0 available in 15 County Region.

IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.

Locations

Blue Cross Medicare Advantage Freedom Blue (PPO) is offered in the following locations.

Blue Earth County, Minnesota
Dodge County, Minnesota
Faribault County, Minnesota

Click to see more locations

Plan Overview

Blue Cross Medicare Advantage Freedom Blue (PPO) offers the following coverage and cost-sharing.

Insurer:Blue Cross and Blue Shield of Minnesota
Health Plan Deductible:$0.00
MOOP:$7,500 In and Out-of-network
$4,900 In-network
Drugs Covered:No

Ready to sign up for Blue Cross Medicare Advantage Freedom Blue (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Premium Breakdown

Blue Cross Medicare Advantage Freedom Blue (PPO) has a monthly premium of $10.00. This amount includes your Part C premium but does not include your Part B premium.
Part B Part C Part B Give Back Total
$164.90 $10.00 $0.00 $174.90
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Blue Cross Medicare Advantage Freedom Blue (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-Network: No

Dental (comprehensive)

Diagnostic services: Not covered (no limits)
Endodontics:In-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Endodontics:Out-of-Network: 0-50% coinsurance (limits may apply) (authorization required) (referral not required)
Extractions:In-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Extractions:Out-of-Network: 0-50% coinsurance (limits may apply) (authorization required) (referral not required)
Non-routine services: Not covered (no limits)
Periodontics:In-Network: 0-50% coinsurance (limits may apply) (authorization required) (referral not required)
Periodontics:Out-of-Network: 0-50% coinsurance (limits may apply) (authorization required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:In-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:Out-of-Network: 0-50% coinsurance (limits may apply) (authorization required) (referral not required)
Restorative services:In-Network: 30% coinsurance (limits may apply) (authorization required) (referral not required)
Restorative services:Out-of-Network: 0-50% coinsurance (limits may apply) (authorization required) (referral not required)

Dental (preventive)

Cleaning:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Cleaning:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Dental x-ray(s):In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Dental x-ray(s):Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Fluoride treatment:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Fluoride treatment:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Oral exam:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Oral exam:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI):In-Network: $0-70 copay (authorization required) (referral not required)
Diagnostic radiology services (e.g., MRI):Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)
Diagnostic tests and procedures:In-Network: $0-20 copay (authorization required) (referral not required)
Diagnostic tests and procedures:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)
Lab services:In-Network: $0 copay (authorization required) (referral not required)
Lab services:Out-of-Network: $0 copay (authorization required) (referral not required)
Outpatient x-rays:In-Network: $0 copay (authorization required) (referral not required)
Outpatient x-rays:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)

Doctor visits

Primary:In-Network: $0-20 copay per visit
Primary:Out-of-Network: $20 copay or 45% coinsurance per visit
Specialist:In-Network: $20-30 copay per visit (authorization required) (referral not required)
Specialist:Out-of-Network: $20 copay or 45% coinsurance per visit (authorization required) (referral not required)

Emergency care/Urgent care

Emergency: $90 copay per visit (always covered)
Urgent care: $35 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment:In-Network: $30 copay (authorization required) (referral not required)
Foot exams and treatment:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)
Routine foot care: Not covered

Ground ambulance

In-Network: $200 copay
Out-of-Network: $200 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

Fitting/evaluation:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Fitting/evaluation:Out-of-Network: $0 copay or 45% coinsurance (no limits) (authorization not required) (referral not required)
Hearing aids:In-Network: $599-899 copay (limits may apply) (authorization not required) (referral not required)
Hearing aids:Out-of-Network: $599-899 copay (limits may apply) (authorization not required) (referral not required)
Hearing exam:In-Network: $0 copay (authorization not required) (referral not required)
Hearing exam:Out-of-Network: $20 copay or 45% coinsurance (authorization not required) (referral not required)

Hospital coverage (inpatient)

In-Network: $200 per stay (authorization required) (referral not required)
Out-of-Network: 45% per stay (authorization required) (referral not required)

Hospital coverage (outpatient)

In-Network: $10-150 copay per visit (authorization required) (referral not required)
Out-of-Network: $20 copay or 45% coinsurance per visit (authorization required) (referral not required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$7,500 In and Out-of-network
$4,900 In-network

Medical equipment/supplies

Diabetes supplies:In-Network: $0 copay per item (authorization not required)
Diabetes supplies:Out-of-Network: $20 copay or 45% coinsurance per item (authorization not required)
Durable medical equipment (e.g., wheelchairs, oxygen):In-Network: 20% coinsurance per item (authorization required)
Durable medical equipment (e.g., wheelchairs, oxygen):Out-of-Network: $20 copay or 45% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):In-Network: 20% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):Out-of-Network: $20 copay or 45% coinsurance per item (authorization required)

Medicare Part B drugs

Chemotherapy:In-Network: 20% coinsurance (authorization required)
Chemotherapy:Out-of-Network: $20 copay or 45% coinsurance (authorization required)
Other Part B drugs:In-Network: 20% coinsurance (authorization required)
Other Part B drugs:Out-of-Network: $20 copay or 45% coinsurance (authorization required)

Mental health services

Inpatient hospital – psychiatric:In-Network: $200 per stay (authorization required) (referral not required)
Inpatient hospital – psychiatric:Out-of-Network: 45% per stay (authorization required) (referral not required)
Outpatient group therapy visit:In-Network: $30 copay (authorization required) (referral not required)
Outpatient group therapy visit:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:In-Network: $30 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)
Outpatient individual therapy visit:In-Network: $30 copay (authorization required) (referral not required)
Outpatient individual therapy visit:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:In-Network: $30 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)

Optional supplemental benefits

No

Preventive care

In-Network: $0 copay (authorization not required) (referral not required)
Out-of-Network: $20 copay or 45% coinsurance (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit:In-Network: $30 copay (authorization required) (referral not required)
Occupational therapy visit:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:In-Network: $20-30 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:Out-of-Network: $20 copay or 45% coinsurance (authorization required) (referral not required)

Skilled Nursing Facility

In-Network: $0 per day for days 1 through 20
$196 per day for days 21 through 100 (authorization required) (referral not required)
Out-of-Network: 45% per stay (authorization required) (referral not required)

Transportation

Not covered

Vision

Contact lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Contact lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses):Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Other: Not covered (no limits)
Routine eye exam:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Routine eye exam:Out-of-Network: $20 copay or 45% coinsurance (limits may apply) (authorization not required) (referral not required)
Upgrades: Not covered

Wellness programs (e.g., fitness, nursing hotline)

Covered (authorization not required) (referral not required)

Ready to sign up for Blue Cross Medicare Advantage Freedom Blue (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Table of Contents

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