Freedom Blue PPO Basic (PPO)
H3916 - 012 - 0
(4.5 / 5)
Freedom Blue PPO Basic (PPO) is a Medicare Advantage (Part C) Plan by Highmark Blue Cross Blue Shield or Highmark Blue S.
This page features plan details for 2024 Freedom Blue PPO Basic (PPO) H3916 – 012 – 0 available in Central and Northeastern PA.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Freedom Blue PPO Basic (PPO) is offered in the following locations.
Plan Overview
Freedom Blue PPO Basic (PPO) offers the following coverage and cost-sharing.
| Insurer: | Highmark Blue Cross Blue Shield or Highmark Blue S |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,950 In and Out-of-network $5,900 In-network |
| Drugs Covered: | No |
Ready to sign up for Freedom Blue PPO Basic (PPO) ?
Premium Breakdown
Freedom Blue PPO Basic (PPO) has a monthly premium of $64.00. 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 | $64.00 | $0.00 | $238.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Freedom Blue PPO Basic (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $8,950 In and Out-of-network $5,900 In-network |
| No |
| In-network | No |
| In-network | $200 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $200 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $35 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $35 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $50 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 (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0-20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $35 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Office visit | $15.00 (Authorization is not required.) (Referral is not required.) |
| out-of-network Office visit | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| Oral exam | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Covered under office visit (Limits may apply.) (Authorization is not 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.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $50 copay (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.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| 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.) |
| In-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network | $125 copay (Not applicable.) (Not applicable.) |
| out-of-network | $125 copay or 30% coinsurance (Not applicable.) (Not applicable.) |
| In-network | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Foot exams and treatment | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $35 copay (Authorization is not required.) (Referral is not required.) |
| In-network Routine foot care | $35 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| 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) | 30% 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) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 30% coinsurance per item (Authorization is 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 | 30% 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 | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $340 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $340 per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $340 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $340 per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $35 copay (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 | 30% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Freedom Blue PPO Basic (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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