Freedom Blue PPO Distinct (PPO) is a Medicare Advantage (Part C) Plan by Highmark Inc..
This page features plan details for 2023 Freedom Blue PPO Distinct (PPO) H8166 – 002 – 0 available in Delaware.
Freedom Blue PPO Distinct (PPO) is offered in the following locations.
Freedom Blue PPO Distinct (PPO) offers the following coverage and cost-sharing.
| Insurer: | Highmark Inc. |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,950 In and Out-of-network $5,500 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Freedom Blue PPO Distinct (PPO) ?
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $33.00 | $0.00 | $197.90 |
Freedom Blue PPO Distinct (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $33.00 | $43.40 | $34.80 | $26.30 | $17.70 |
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $7.00 copay | ||
| 2 (Generic) | $0.00 copay | $15.00 copay | ||
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $21.00 copay | $0.00 copay | $21.00 copay |
| 2 (Generic) | $0.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
| 3 (Preferred Brand) | $141.00 copay | $141.00 copay | $120.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | $275.00 copay | $300.00 copay |
| 5 (Specialty Tier) |
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Freedom Blue PPO Distinct (PPO) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | In-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | Out-of-Network: 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: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | Not covered (no limits) |
| 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: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | In-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Cleaning: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | In-Network: $15 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | Out-of-Network: 30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Not covered (no limits) |
| Office visit: | In-Network: $15.00 (authorization not required) (referral not required) |
| Office visit: | Out-of-Network: 30% coinsurance (authorization not required) (referral not required) |
| Oral exam: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | In-Network: $150 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: $300 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $0-10 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: $40 copay (authorization required) (referral not required) |
| Lab services: | In-Network: $0-10 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: $40 copay (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $10 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: $40 copay (authorization required) (referral not required) |
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $0 copay |
| Specialist: | In-Network: $0 copay (authorization not required) (referral not required) |
| Specialist: | Out-of-Network: $0 copay (authorization not required) (referral not required) |
| Emergency: | $95 copay per visit (always covered) |
| Urgent care: | $0 copay |
| Foot exams and treatment: | In-Network: $0 copay (authorization not required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $0 copay (authorization not required) (referral not required) |
| Routine foot care: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine foot care: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| In-Network: $250 copay | |
| Out-of-Network: $250 copay or 30% coinsurance |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | Not covered (no limits) |
| Hearing aids: | In-Network: $699-999 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | Out-of-Network: $0 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: $0 copay (authorization not required) (referral not required) |
| In-Network: $295 per stay (authorization required) (referral not required) | |
| Out-of-Network: $395 per stay (authorization required) (referral not required) |
| In-Network: $200 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: $300 copay per visit (authorization required) (referral not required) |
| $8,950 In and Out-of-network $5,500 In-network |
| Diabetes supplies: | In-Network: 0-20% coinsurance per item (authorization required) |
| Diabetes supplies: | Out-of-Network: 30% coinsurance per item (authorization 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: 30% 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: 30% coinsurance per item (authorization required) |
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 30% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 30% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | In-Network: $425 per day for days 1 through 3 $0 per day for days 4 through 90 (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: $500 per day for days 1 through 3 $0 per day for days 4 through 90 (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: $40 copay (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: $40 copay (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: $40 copay (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: $40 copay (authorization required) (referral not required) |
| No |
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: $0 copay (authorization not required) (referral not required) |
| Occupational therapy visit: | In-Network: $30 copay (authorization required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: $40 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $0 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $40 copay (authorization required) (referral not required) |
| 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: 30% per stay (authorization required) (referral not required) |
| Not covered |
| 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): | Not covered (no limits) |
| 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: $50 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Covered (authorization not required) (referral not required) |
Ready to sign up for Freedom Blue PPO Distinct (PPO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
Factsonmedicare.com is a free-to-use informational website by Dog Media Solutions LLC. All insurance agents and enrollment platforms linked to this site have their own terms and conditions.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B Premium give-back is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do feature in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
HealthCompare Insurance Services does not offer every plan available in your area. Currently we represent 18 organizations, which offers 52,101 products in your area.
We do not feature every plan available in your area. Any information we provide is limited to those plans we do feature in your area. Enrollment is offered through our partners including HealthCompare Insurance Services Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
HealthCompare Insurance Services represents Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.
Medicare has neither approved nor endorsed any information on this site.