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Freedom Blue PPO Select (PPO)

4.5 out of 5 stars* for plan year 2024
$158.00 Monthly Premium

Freedom Blue PPO Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health

Plan ID: H3916-022-000

$158.00 Monthly Premium

Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$158.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$5,000.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $30.00
Inpatient hospital care
Out-of-Network:
Copayment for Acute Hospital Services per Stay $350.00
Urgent care
Urgent Care:
Copayment for Urgent Care $5.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $5.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $215.00
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $215.00

Air Ambulance:
Copayment for Air Ambulance Services $215.00

Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip.
Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Freedom Blue PPO Select (PPO) covers a range of additional benefits. Learn more about Freedom Blue PPO Select (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $15.00
Chiropractic Services:
Copayment for Non-Medicare Covered Chiropractic Services $15.00
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $15.00
Copayment for Medicare-covered Lab Services $0.00 to $15.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $125.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $20.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $350.00
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care
Out-of-Network:

Outpatient Mental Health Services:
Copayment for Medicare Covered Individual Sessions $30.00
Copayment for Medicare Covered Group Sessions $30.00
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $175.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $125.00
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Substance Abuse Services
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30.00
Copayment for Routine Foot Care $30.00
  • Maximum 10 visits every year
Skilled Nursing Facility (SNF) care
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-Network:

Preventive Dental:

Copayment for Office Visit $15.00 including:

Oral Exams

  • Maximum 1 visit every six months

Prophylaxis (Cleaning)

  • Maximum 1 visit every six months

Dental X-Rays

  • Maximum 1 visit every year

Comprehensive Dental:
Copayment for Medicare-covered Benefits $30.00

Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $30.00
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 30%

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Standard Eyeglass lenses and frames or contact lenses are covered in full. A $175 benefit maximum applies to non-standard frames or specialty contact lenses.

Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $30.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $50.00
Standard Eyeglass lenses and frames or contact lenses are covered in full. A $175 benefit maximum applies to non-standard frames or specialty contact lenses.

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $599.00 to $899.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $500.00 every year both ears combined for in and out of network services combined
You must see a TruHearing provider to use this benefit. Up to two TruHearing hearing aids every year (one per ear per year). Benefit is limited to the TruHearing Advanced ($599) and Premium ($899) hearing aids, which come in various styles and colors, and are available in rechargeable style options. Hearing aid purchase includes: - First year of follow-up provider visits - 60-day trial period - 3-year extended warranty - 80 batteries per aid for non-rechargeable models Members have a $500 maximum allowance towards hearing aids that are not the TruHearing Advanced or Premium models.

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programs
Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Pennsylvania Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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