NextBlue Freedom PPO (PPO)
H6202 - 003 - 0
(4.5 / 5)
NextBlue Freedom PPO (PPO) is a Medicare Advantage (Part C) Plan by NextBlue of North Dakota.
This page features plan details for 2024 NextBlue Freedom PPO (PPO) H6202 – 003 – 0 available in North Dakota.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
NextBlue Freedom PPO (PPO) is offered in the following locations.
Plan Overview
NextBlue Freedom PPO (PPO) offers the following coverage and cost-sharing.
| Insurer: | NextBlue of North Dakota |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,500 In and Out-of-network $4,500 In-network |
| Drugs Covered: | No |
Ready to sign up for NextBlue Freedom PPO (PPO) ?
Premium Breakdown
NextBlue Freedom PPO (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 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
NextBlue Freedom PPO (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $4,500 In and Out-of-network $4,500 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 | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $25 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 | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $40 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-325 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $0-325 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 | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-325 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $0-325 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient x-rays | $15 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $15 copay (Authorization is not required.) (Referral is not required.) |
| In-network Hearing exam | $5-25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $5-25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $0 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 Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (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 Cleaning | $0 copay (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 treatment | $0 copay (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) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Diagnostic services | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic services | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Restorative services | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Restorative services | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Endodontics | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Endodontics | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Periodontics | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Periodontics | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Extractions | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Extractions | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 25% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 40% coinsurance (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 | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | 50% coinsurance (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 | 50% coinsurance (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 | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $150 copay (Not applicable.) (Not applicable.) |
| out-of-network | $150 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% 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) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| out-of-network Diabetes supplies | 0-20% coinsurance per item (Authorization is not 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 | $35 copay or 20-30% 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 | $35 copay or 20-30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | $35 copay or 20-30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $350 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $350 per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $350 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $350 per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $125 per day for days 21 through 48 $0 per day for days 49 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 20 $125 per day for days 21 through 48 $0 per day for days 49 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for NextBlue Freedom PPO (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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