2022 Freedom Blue PPO Basic (PPO)


Freedom Blue PPO Basic (PPO) H3916-012 is a 2022 Medicare Advantage Plan or Part-C by Highmark Inc available to residents in Pennsylvania. This plan does not provide additional prescription drug (Part-D) coverage. The Freedom Blue PPO Basic (PPO) has a monthly premium of $65.00 and has an in-network maximum out-of-pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out-of-pocket. This can be a extremely nice safety net.

Freedom Blue PPO Basic (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Highmark Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Freedom Blue PPO Basic (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Highmark Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Highmark Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Highmark Inc Medicare Advantage Plan Costs

Name:
Freedom Blue PPO Basic (PPO)
Plan ID:
H3916-012
Provider:Highmark Inc
Year:2022
Type: Local PPO *
Monthly Premium C+D: $65.00
Part C Premium:
MOOP: $5,900
Similar Plan: H3916-015
New Plan: 2023 H3916-015




2021 Freedom Blue PPO Basic (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services Not covered
Endodontics Not covered
Extractions Not covered
Non-routine services Not covered
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered
Restorative services Not covered



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $150 copay
Diagnostic radiology services (e.g., MRI) $150 copay (Out-of-Network)
Diagnostic tests and procedures $20 copay (Out-of-Network)
Diagnostic tests and procedures $0-20 copay
Lab services $20 copay (Out-of-Network)
Lab services $0-20 copay
Outpatient x-rays $25 copay (Out-of-Network)
Outpatient x-rays $25 copay



Doctor Visits


Primary $0 copay (Out-of-Network)
Primary $0 copay
Specialist $35 copay per visit
Specialist $35 copay per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $50 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $35 copay
Foot exams and treatment $35 copay (Out-of-Network)
Routine foot care $35 copay
Routine foot care $35 copay (Out-of-Network)



Ground Ambulance


$125 copay
$125 copay or 30% coinsurance (Out-of-Network)



Hearing


Fitting/evaluation Not covered
Hearing aids $0 copay (Out-of-Network)
Hearing aids $699-999 copay
Hearing exam $35 copay (Out-of-Network)
Hearing exam $35 copay



Inpatient Hospital Coverage


$340 per stay
$340 per stay (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies 0-20% coinsurance per item
Diabetes supplies 30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Chemotherapy 30% coinsurance (Out-of-Network)
Other Part B drugs 30% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $340 per stay (Out-of-Network)
Inpatient hospital - psychiatric $340 per stay
Outpatient group therapy visit $35 copay
Outpatient group therapy visit $35 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $35 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $35 copay
Outpatient individual therapy visit $35 copay
Outpatient individual therapy visit $35 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $35 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $35 copay



MOOP


$10,000 In and Out-of-network
$5,900 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$200 copay per visit (Out-of-Network)
$200 copay per visit



Preventive Care


$0 copay
$0 copay (Out-of-Network)



Preventive Dental


Cleaning Covered under office visit
Dental x-ray(s) 30% coinsurance (Out-of-Network)
Dental x-ray(s) $15 copay
Fluoride treatment Not covered
Office visit 30% coinsurance (Out-of-Network)
Office visit $15.00
Oral exam Covered under office visit



Rehabilitation Services


Occupational therapy visit $35 copay
Occupational therapy visit $35 copay (Out-of-Network)
Physical therapy and speech and language therapy visit $35 copay
Physical therapy and speech and language therapy visit $35 copay (Out-of-Network)



Skilled Nursing Facility


$0 per day for days 1 through 20
$184 per day for days 21 through 100
30% per stay (Out-of-Network)



Transportation


$10 copay
30% coinsurance (Out-of-Network)



Vision


Contact lenses $0 copay (Out-of-Network)
Contact lenses $0 copay
Eyeglass frames $0 copay
Eyeglass frames $0 copay (Out-of-Network)
Eyeglass lenses $0 copay (Out-of-Network)
Eyeglass lenses $0 copay
Eyeglasses (frames and lenses) Not covered
Other Not covered
Routine eye exam $0 copay
Routine eye exam $50 copay (Out-of-Network)
Upgrades $0 copay
Upgrades $0 copay (Out-of-Network)



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Freedom Blue PPO Basic (PPO) H3916



2021 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Freedom Blue PPO Basic (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Freedom Blue PPO Basic (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Freedom Blue PPO Basic (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST




Coverage Area for Freedom Blue PPO Basic (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

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