2027 Medicare Advantage plan

Freedom Blue PPO Standard (PPO): 2027 benefits and costs

Highmark Blue Cross Blue Shield PPO

CMS plan ID: H5106-034-2 · Plan year: 2027

Freedom Blue PPO Standard (PPO) is a 2027 Medicare Advantage plan offered by Highmark Blue Cross Blue Shield. It is listed in West Virginia.

2027 plan costs at a glance

Monthly plan premium$172.00

Drug deductible$700.00

In-network medical out-of-pocket maximum$6,500.00

Organization: Highmark Blue Cross Blue Shield
Plan organization: HIGHMARK SENIOR SOLUTIONS COMPANY
Parent company: Highmark Health
Plan type: PPO
Part C premium: $42.80
Part D premium: $129.20
Prescription drug coverage: Yes
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

Annual medical deductible: None
In-network medical maximum: $6,500.00
Combined in/out-of-network medical maximum: $10,750.00
Out-of-network medical maximum: Not applicable

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	Out-of-network	What to know
Primary care doctor	$0 Service-specific deductible No	$0 Deductible applies No
Specialist visit	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Telehealth	$0.00 to $50.00 copay Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Emergency care	$130.00 copay	Not summarized. Check coverage with the plan.
Urgent care	$50.00 copay	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	20% to 30% coinsurance Deductible applies No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	30% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	30% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Medicare-covered chiropractic	$15.00 copay Service-specific deductible No	$15.00 copay Deductible applies No	Approval required No Referral required No
Medicare-covered foot care	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Other health professionals	$0.00 to $35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–7: $150.00 copay per day Days 8–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient mental health care	$0.00 copay per stay Days 1–7: $150.00 copay per day Days 8–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Skilled nursing facility	Days 1–20: $0.00 copay per day Days 21–100: $221.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	Out-of-network	What to know
Outpatient hospital care	$0.00 to $150.00 copay Service-specific deductible No	$150.00 copay Deductible applies No
Hospital observation services	$150.00 copay Service-specific deductible No	$150.00 copay Deductible applies No
Ambulatory surgical center	$0.00 to $100.00 copay Service-specific deductible No	$100.00 copay Deductible applies No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	Out-of-network	What to know
Diagnostic procedures and tests	$0.00 to $10.00 copay Service-specific deductible No	$10.00 copay Deductible applies No	Approval required Yes Referral required No
Laboratory services	$0.00 to $10.00 copay Service-specific deductible No	$10.00 copay Deductible applies No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$75.00 copay Service-specific deductible No	$75.00 copay Deductible applies No	Approval required Yes Referral required No
Therapeutic radiology	$60.00 copay Service-specific deductible No	$60.00 copay Deductible applies No	Approval required Yes Referral required No
X-rays	$25.00 copay Service-specific deductible No	$25.00 copay Deductible applies No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	Out-of-network	What to know
Partial hospitalization	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes Referral required No
Intensive outpatient program	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes Referral required No
Substance use treatment, individual sessions	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Substance use treatment, group sessions	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Opioid treatment program	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Mental health, individual sessions	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required Yes Referral required No
Mental health, group sessions	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required Yes Referral required No
Psychiatry, individual sessions	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Psychiatry, group sessions	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	Out-of-network	What to know
Occupational therapy	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required Yes Referral required No
Physical and speech therapy	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required Yes Referral required No
Cardiac rehabilitation	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required No Referral required No
Intensive cardiac rehabilitation	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required No Referral required No
Pulmonary rehabilitation	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$0 Service-specific deductible No	30% coinsurance Deductible applies No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	Out-of-network	What to know
Ground ambulance	$330.00 copay Service-specific deductible No	$330.00 copay; 30% coinsurance Deductible applies No	Approval required Yes
Air ambulance	$330.00 copay Service-specific deductible No	$330.00 copay; 30% coinsurance Deductible applies No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Diabetic supplies	0% to 20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Diabetic monitors	0% to 20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	Out-of-network
Medicare-covered dental	$35.00 copay	$35.00 copay Deductible applies No
Oral examsAdditional plan benefit	$0	30% coinsurance Deductible applies No
Dental X-raysAdditional plan benefit	$0	30% coinsurance Deductible applies No
Dental cleaningAdditional plan benefit	$0	30% coinsurance Deductible applies No

Additional network details

These costs apply to the listed service categories and networks.

Dental benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Diagnostic and preventive dental (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Vision benefits

Vision benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered eye exams	$0.00 to $35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	$50.00 copay Deductible applies No	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0.00 to $40.00 copay	$0 Deductible applies No	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0.00 to $40.00 copay	$0 Deductible applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Vision benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Eye exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Eyewear (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
UpgradesAdditional plan benefit	Out-of-network	$0 Deductible applies No

Hearing benefits

Hearing benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered hearing exams	$35.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	$35.00 copay Deductible applies No	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$399.00 to $699.00 copay Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Hearing benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Hearing exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Prescription hearing aids (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Extra benefits

Extra benefits and member costs
Service	In-network	Out-of-network	What to know
Limited-duration mealsAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Annual physical examAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	50% coinsurance Deductible applies Yes Deductible amount $500.00 Dollar benefit limit applies No	Approval required No Referral required No

Additional services and network costs

Additional network details

These costs apply to the listed service categories and networks.

Additional medical services: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Chiropractic ServicesAdditional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Routine Chiropractic CareAdditional plan benefit	Out-of-network	$15.00 copay Deductible applies No
Podiatry Services - Routine Foot CareAdditional plan benefit	Out-of-network	$35.00 copay Deductible applies No	Dollar benefit limit applies No
Medicare-covered preventive servicesMedicare-covered care	Out-of-network	$0 Deductible applies No
Enhanced Disease ManagementAdditional plan benefit	Out-of-network	$0 Deductible applies No	Dollar benefit limit applies No
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)Additional plan benefit	Out-of-network	$0.00 to $35.00 copay Deductible applies No	Dollar benefit limit applies No
Home and Bathroom Safety Devices and ModificationsAdditional plan benefit	Out-of-network	30% coinsurance Deductible applies No	Dollar benefit limit applies No
Glaucoma ScreeningMedicare-covered care	Out-of-network	$0 Deductible applies No
Diabetes Self-Management TrainingMedicare-covered care	Out-of-network	$0 Deductible applies No
Digital Rectal ExamsMedicare-covered care	Out-of-network	$0 Deductible applies No
EKG after a Welcome to Medicare visitMedicare-covered care	Out-of-network	$0 Deductible applies No
Medicare Part B insulinMedicare-covered care	Out-of-network	$35.00 copay Deductible applies No

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2 are exempt from the deductible.

Preferred retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Preferred retail: initial-coverage cost per prescription fill
Drug tier	31 days	90 days	100 days
Tier 1Preferred Generic	$0.00	Not listed	$0.00
Tier 2Generic	$5.00	Not listed	$15.00
Tier 3Preferred Brand	19%	19%	Not listed
Tier 4Non-Preferred Drug	25%	25%	Not listed
Tier 5Specialty Tier	25%	Not listed	Not listed

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	31 days	90 days	100 days
Tier 1Preferred Generic	$6.00	Not listed	$18.00
Tier 2Generic	$20.00	Not listed	$60.00
Tier 3Preferred Brand	19%	19%	Not listed
Tier 4Non-Preferred Drug	25%	25%	Not listed
Tier 5Specialty Tier	25%	Not listed	Not listed

Mail-order and other pharmacies

Out-of-network pricing: The standard retail copay or coinsurance applies, without an added difference between the billed charge and the plan’s allowed amount. The plan’s out-of-network coverage rules still apply.

Preferred mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Preferred mail order: initial-coverage cost per prescription fill
Drug tier	31 days	90 days	100 days
Tier 1Preferred Generic	Not listed	Not listed	$0.00
Tier 2Generic	Not listed	Not listed	$7.00
Tier 3Preferred Brand	Not listed	19%	Not listed
Tier 4Non-Preferred Drug	Not listed	25%	Not listed
Tier 5Specialty Tier	25%	Not listed	Not listed

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	31 days	90 days	100 days
Tier 1Preferred Generic	Not listed	Not listed	$15.00
Tier 2Generic	Not listed	Not listed	$57.00
Tier 3Preferred Brand	Not listed	19%	Not listed
Tier 4Non-Preferred Drug	Not listed	25%	Not listed
Tier 5Specialty Tier	25%	Not listed	Not listed

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$6.00
Tier 2Generic	$20.00
Tier 3Preferred Brand	19%
Tier 4Non-Preferred Drug	25%
Tier 5Specialty Tier	25%

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$6.00
Tier 2Generic	$20.00
Tier 3Preferred Brand	19%
Tier 4Non-Preferred Drug	25%
Tier 5Specialty Tier	25%

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 25 county listings across 1 state or territory