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Freedom Blue PPO ValueRx (PPO) - H3916-032-000
$79.00
Monthly Premium
Freedom Blue PPO ValueRx (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-032-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$79.00
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 additional 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.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $79.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,500.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40 |
| Inpatient hospital care | In-Network: Acute Hospital Services: $220 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care. |
| Urgent care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $50 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $130 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation $275 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275 Coinsurance for Medicare Covered Ambulance Services - Ground 30% Copayment for Medicare Covered Ambulance Services - Air $275 Coinsurance for Medicare Covered Ambulance Services - Air 30% Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. |
Health Care Services and Medical Supplies
Freedom Blue PPO ValueRx (PPO) covers a range of additional benefits. Learn more about Freedom Blue PPO ValueRx (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network:
|
| 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-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $20 Copayment for Medicare-covered Lab Services $0 to $20 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services The minimum copayment applies for Medicare-covered diagnostic procedures/tests and lab services provided at free standing labs. The maximum copayment applies for Medicare-covered diagnostic procedures/tests and lab services at all other places of service. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $200 Copayment for Medicare-covered Therapeutic Radiological Services $60 Copayment for Medicare-covered X-Ray Services $20 |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 30% |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: $220 per day for days 1 to 5 $0 per day for days 6 to 90 Private accommodations will be covered when medically necessary. Inpatient substance abuse is subject to the same cost sharing as Inpatient Psychiatric Hospital. |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $200 Copayment for Medicare Covered Ambulatory Surgical Center Services $175 Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment. |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $40 Copayment for Medicare Covered Group Sessions $40 |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 Copayment for Routine Foot Care $40
|
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Private accommodations will be covered when medically necessary. |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | Out-of-Network: Preventive Dental Services: Copayment for Preventive Dental $40 |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Eye Exams Services: Copayment for Medicare Covered Eye Exams $40 Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $599 to $899
Members must use our contracted provider to use this benefit. Up to two hearing aids every year (one per ear per year). Benefit is limited to the Advanced (minimum cost sharing) and Premium (maximum cost sharing) hearing aids, which come in various styles and colors, and are available in rechargeable style options at no additional charge.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 modelsBenefit does not include or cover any of the following: • Additional cost for optional hearing aid rechargeability • Ear molds • Hearing aid accessories • Additional provider visits • Additional batteries - batteries when a rechargeable hearing aid is purchased • Hearing aids that are not TruHearing-branded hearing aids • Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan.Services not covered under any condition:Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), ear molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the 80 free batteries per non-rechargeable aid purchased).Members have a $500 maximum allowance towards hearing aids that are not the 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 Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
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 offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Healthspring, Wellcare, or Kaiser Permanente.