Freedom Blue PPO Valor (PPO)

H3916 - 042 - 1
4.5 out of 5 stars (4.5 / 5)

Freedom Blue PPO Valor (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 Valor (PPO) H3916 – 042 – 1 available in Southwestern PA.

IMPORTANT: This page has been updated with plan and premium data for 2024.

Locations

Freedom Blue PPO Valor (PPO) is offered in the following locations.

Plan Overview

Freedom Blue PPO Valor (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
$6,000 In-network
Drugs Covered:No

Ready to sign up for Freedom Blue PPO Valor (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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. 

Freedom Blue PPO Valor (PPO) qualifies for a monthly Medicare Give Back Benefit of $60.00.

Premium Reduction:$60.00

Premium Breakdown

Freedom Blue PPO Valor (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 $60.00 $114.70
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Freedom Blue PPO Valor (PPO) also provides the following benefits.

Health plan deductible

$0

Other health plan deductibles?

In-network No

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

$8,950 In and Out-of-network
$6,000 In-network

Optional supplemental benefits

No

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

In-network No

Outpatient hospital coverage

In-network $245 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network $375 copay per visit (Authorization is required.) (Referral is not required.)

Doctor visits

In-network Primary$0 copay (Not applicable.) (Not applicable.)
out-of-network Primary$0 copay (Not applicable.) (Not applicable.)
In-network Specialist$10 copay per visit (Authorization is not required.) (Referral is not required.)
out-of-network Specialist$10 copay per visit (Authorization is not required.) (Referral is not required.)

Preventive care

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 care/Urgent care

Emergency$100 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$50 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

In-network Diagnostic tests and procedures$0 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic tests and procedures$35 copay (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$35 copay (Authorization is required.) (Referral is not required.)
In-network Diagnostic radiology services (e.g., MRI)$225 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic radiology services (e.g., MRI)$325 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient x-rays$20 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient x-rays$35 copay (Authorization is required.) (Referral is not required.)

Hearing

In-network Hearing exam$10 copay (Authorization is not required.) (Referral is not required.)
out-of-network Hearing exam$10 copay (Authorization is not required.) (Referral is not required.)
Fitting/evaluationNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Hearing aids$699-999 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.)

Preventive dental

In-network Oral exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Oral exam30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Cleaning$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Cleaning30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Fluoride treatment$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Fluoride treatment30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Dental x-ray(s)30% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Comprehensive dental

In-network Non-routine services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Non-routine services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Diagnostic services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Restorative services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Restorative services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Endodontics20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Endodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Periodontics20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Periodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Extractions20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Extractions50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Prosthodontics, other oral/maxillofacial surgery, other services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Prosthodontics, other oral/maxillofacial surgery, other services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Vision

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.)
OtherNot 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.)

Rehabilitation services

In-network Occupational therapy visit$15 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$15 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.)

Ground ambulance

In-network $250 copay (Not applicable.) (Not applicable.)
out-of-network $250 copay or 30% coinsurance (Not applicable.) (Not applicable.)

Transportation

In-network $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)

Foot care (podiatry services)

In-network Foot exams and treatment$10 copay (Authorization is not required.) (Referral is not required.)
out-of-network Foot exams and treatment$10 copay (Authorization is not required.) (Referral is not required.)
In-network Routine foot care$10 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Medical equipment/supplies

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 supplies0-20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Diabetes supplies30% coinsurance per item (Authorization is required.) (Not applicable.)

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

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

In-network Chemotherapy0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy30% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs30% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs30% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network $275 per stay (Authorization is required.) (Referral is not required.)
out-of-network $395 per stay (Authorization is required.) (Referral is not required.)

Mental health services

In-network Inpatient hospital – psychiatric$325 per day for days 1 through 3
$0 per day for days 4 through 90 (Authorization is required.) (Referral is not required.)
out-of-network Inpatient hospital – psychiatric$475 per day for days 1 through 3
$0 per day for days 4 through 90 (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit with a psychiatrist$5 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$5 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$5 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$5 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit$35 copay (Authorization is required.) (Referral is not required.)

Skilled Nursing Facility

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 Valor (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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