Blue Cross Medicare Advantage Freedom Blue (PPO)
H5959 - 018 - 0
(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 2024 Blue Cross Medicare Advantage Freedom Blue (PPO) H5959 – 018 – 0 available in 66 County Region.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Blue Cross Medicare Advantage Freedom Blue (PPO) is offered in the following 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 $4,200 In-network |
| Drugs Covered: | No |
Ready to sign up for Blue Cross Medicare Advantage Freedom Blue (PPO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Blue Cross Medicare Advantage Freedom Blue (PPO) qualifies for a monthly Medicare Give Back Benefit of $100.00.
| Premium Reduction: | $100.00 |
Premium Breakdown
Blue Cross Medicare Advantage Freedom Blue (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $100.00 | $74.70 |
- 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.
| $0 |
| In-network | No |
| $7,500 In and Out-of-network $4,200 In-network |
| No |
| In-network | No |
| In-network | $10-150 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $20 copay or 40% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0-20 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $20 copay or 40% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $20-30 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network Specialist | $20 copay or 40% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $20 copay or 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-70 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $20 copay or 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $0 copay or 40% coinsurance (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Oral exam | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Cleaning | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Fluoride treatment | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Restorative services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 0-20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 40% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $20-30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $200 copay (Not applicable.) (Not applicable.) |
| out-of-network | $200 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | $20 copay or 40% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | $20 copay or 40% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| out-of-network Diabetes supplies | $20 copay or 40% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | $20 copay or 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | $20 copay or 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $0-35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | $20 copay or 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $200 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | 40% per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $200 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 40% per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $20 copay or 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 40% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Blue Cross Medicare Advantage Freedom Blue (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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