2022 Freedom Blue PPO Standard (PPO)

Freedom Blue PPO Standard (PPO) H3916-015 is a 2022 Medicare Advantage Plan or Part-C by Highmark Inc available to residents in Pennsylvania. This plan includes additional prescription drug (Part-D) coverage. The Freedom Blue PPO Standard (PPO) has a monthly premium of $174.00 and has an in-network maximum out-of-pocket limit of $5,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,000 out-of-pocket. This can be a extremely nice safety net.

Freedom Blue PPO Standard (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 Standard (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

Freedom Blue PPO Standard (PPO) Part-C Premium

Highmark Inc charges a $74.70 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H3916-015 Part-D Deductible and Premium

Freedom Blue PPO Standard (PPO) has a monthly drug premium of $59.30 and a $0.00 drug deductible. This Highmark Inc plan offers a $59.30 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $40.00 this Premium covers any enhanced plan benefits offered by Highmark Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $99.30 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Highmark Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Highmark Inc plan does not offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Freedom Blue PPO Standard (PPO) medicare insurance offers a $58.60 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $68.70 for 75% low income subsidy $78.90 for 50% and $89.10 for 25%.

H3916-015 Formulary or Drug Coverage

Freedom Blue PPO Standard (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Freedom Blue PPO Standard (PPO) H3916-015 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$13	$19
Tier 3	$45	$47
Tier 4	$95	$100
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 Freedom Blue PPO Standard (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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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

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Deductible

$0

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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	$15 copay (Out-of-Network)
Diagnostic tests and procedures	$0-15 copay
Lab services	$15 copay (Out-of-Network)
Lab services	$0-15 copay
Outpatient x-rays	$20 copay (Out-of-Network)
Outpatient x-rays	$20 copay

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Doctor Visits

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

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Emergency care/Urgent Care

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

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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)

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Ground Ambulance

$225 copay
$225 copay or 30% coinsurance (Out-of-Network)

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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

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Inpatient Hospital Coverage

$475 per stay
$475 per stay (Out-of-Network)

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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

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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

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Mental Health Services

Inpatient hospital - psychiatric	$475 per stay (Out-of-Network)
Inpatient hospital - psychiatric	$475 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

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MOOP

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

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$250 copay per visit (Out-of-Network)
$250 copay per visit

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Preventive Care

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

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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

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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)

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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)

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Transportation

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

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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)

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Wellness Programs (e.g. fitness nursing hotline)

Covered

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

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

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

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

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

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

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 Standard (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.