Freedom Platinum Rewards Plan Rx (HMO)
H5427 - 102 - 0
(4.5 / 5)
Freedom Platinum Rewards Plan Rx (HMO) is a Medicare Advantage (Part C) Plan by Freedom Health, Inc..
This page features plan details for 2024 Freedom Platinum Rewards Plan Rx (HMO) H5427 – 102 – 0 available in select counties in FL.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Freedom Platinum Rewards Plan Rx (HMO) is offered in the following locations.
Plan Overview
Freedom Platinum Rewards Plan Rx (HMO) offers the following coverage and cost-sharing.
| Insurer: | Freedom Health, Inc. |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,400 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Freedom Platinum Rewards Plan Rx (HMO) ?
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 Platinum Rewards Plan Rx (HMO) qualifies for a monthly Medicare Give Back Benefit of $164.90.
| Premium Reduction: | $164.90 |
Premium Breakdown
Freedom Platinum Rewards Plan Rx (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $164.90 | $9.80 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Freedom Platinum Rewards Plan Rx (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $0.00 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
Initial Coverage Phase
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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Preferred Brand) | $35.00 copay | $35.00 copay | ||
| 3 (Non-Preferred Drug) | $85.00 copay | $85.00 copay | ||
| 4 (Specialty Tier) | 33% | 33% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Preferred Brand) | ||||
| 3 (Non-Preferred Drug) | ||||
| 4 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Preferred Brand) | $105.00 copay | $70.00 copay | ||
| 3 (Non-Preferred Drug) | $255.00 copay | $170.00 copay | ||
| 4 (Specialty Tier) |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs | ||||
| 1 (Preferred Generic) | ||||
| 2 (Preferred Brand) | ||||
| 3 (Non-Preferred Drug) | ||||
| 4 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs | ||||
| 1 (Preferred Generic) | ||||
| 2 (Preferred Brand) | ||||
| 3 (Non-Preferred Drug) | ||||
| 4 (Specialty Tier) |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
Freedom Platinum Rewards Plan Rx (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,400 In-network |
| No |
| In-network | No |
| $195 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $10 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is required.) (Referral is required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $10 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-195 copay or 20% coinsurance (Authorization is required.) (Referral is required.) |
| Lab services | $0-50 copay (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $25-195 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0-195 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | $30 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| $175 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $10 copay (Authorization is required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $195 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $195 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $10 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $10 copay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| $0 per day for days 1 through 20 $150 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for Freedom Platinum Rewards Plan Rx (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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