2023 Freedom Blue PPO Valor (PPO)

Freedom Blue PPO Valor (PPO) H8166-003 is a 2023 Medicare Advantage Plan or Part-C by Highmark Inc. available to residents in Delaware. This plan does not provide extra prescription drug (Part-D) coverage. Highmark Inc. Freedom Blue PPO Valor (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,000 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $6,000 out-of-pocket. This can be an extremely nice safety net.

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 Valor (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Highmark Inc. and not Original Medicare. With 2023 Medicare Advantage Plan 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 if you sign up for Medicare Advantage in Delaware.

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Benefits
Monthly Costs
MOOP
Coverage Area

2023 Highmark Inc. Medicare Advantage Plan Overview

Name:	Freedom Blue PPO Valor (PPO)
Plan ID:	H8166 003 0
Provider:	Highmark Inc.
Year:	2023
Type:	Local PPO *
Combined Premium (C+D):	$0/mo
MOOP:	$6,000/yr
Similar Plan:	H8166-001

What type of plan is Freedom Blue PPO Valor (PPO)

Freedom Blue PPO Valor (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.

How much does Freedom Blue PPO Valor (PPO) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Highmark Inc. charges a $0 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.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Freedom Blue PPO Valor (PPO) by Highmark Inc. MOOP is $6,000. Once you spend $6,000 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

2023 Summary of Benefits

The benefit information provided is a summary of what Freedom Blue PPO Valor (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Highmark Inc. helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

Contact lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

Eyeglass frames

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

Eyeglass lenses

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

Eyeglasses (frames and lenses)

Vision	Not covered

Other

Vision	Not covered

Routine eye exam

Out-of-Network Vision	$50 copay
In-Network Vision	$0 copay

Upgrades

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

Transportation	Not covered
Out-of-Network Skilled Nursing Facility	30% per stay
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100

Occupational therapy visit

In-Network Rehabilitation services	$15 copay
Out-of-Network Rehabilitation services	$35 copay

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$15 copay
Out-of-Network Rehabilitation services	$35 copay

Cleaning

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	30% coinsurance

Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	30% coinsurance

Fluoride treatment

Preventive dental	Not covered

Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	30% coinsurance

In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$245 copay per visit
Out-of-Network Outpatient hospital coverage	$375 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

Inpatient hospital - psychiatric

In-Network Mental health services	$325 per day for days 1 through 3 $0 per day for days 4 through 90
Out-of-Network Mental health services	$475 per day for days 1 through 3 $0 per day for days 4 through 90

Outpatient group therapy visit

In-Network Mental health services	$5 copay
Out-of-Network Mental health services	$35 copay

Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$5 copay
Out-of-Network Mental health services	$35 copay

Outpatient individual therapy visit

Out-of-Network Mental health services	$35 copay
In-Network Mental health services	$5 copay

Outpatient individual therapy visit with a psychiatrist

Out-of-Network Mental health services	$35 copay
In-Network Mental health services	$5 copay

Chemotherapy

Out-of-Network Medicare Part B drugs	30% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

Diabetes supplies

In-Network Medical equipment/supplies	0-20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$8,950 In and Out-of-network $6,000 In-network
In-Network Inpatient hospital coverage	$275 per stay
Out-of-Network Inpatient hospital coverage	$395 per stay

Fitting/evaluation

Hearing	Not covered

Hearing aids

In-Network Hearing	$699-999 copay
Out-of-Network Hearing	$0 copay

Hearing exam

Out-of-Network Hearing	$10 copay
In-Network Hearing	$10 copay

Health plan deductible	$0
In-Network Ground ambulance	$250 copay
Out-of-Network Ground ambulance	$250 copay or 30% coinsurance

Foot exams and treatment

In-Network Foot care (podiatry services)	$10 copay
Out-of-Network Foot care (podiatry services)	$10 copay

Routine foot care

In-Network Foot care (podiatry services)	$10 copay
Out-of-Network Foot care (podiatry services)	$10 copay

Emergency

Emergency care/Urgent care	$95 copay per visit (always covered)

Urgent care

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

Primary

Out-of-Network Doctor visits	$0 copay
In-Network Doctor visits	$0 copay

Specialist

In-Network Doctor visits	$10 copay per visit
Out-of-Network Doctor visits	$10 copay per visit

Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$225 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$325 copay

Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	$35 copay
In-Network Diagnostic procedures/lab services/imaging	$0 copay

Lab services

Out-of-Network Diagnostic procedures/lab services/imaging	$35 copay
In-Network Diagnostic procedures/lab services/imaging	$0 copay

Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$20 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$35 copay

Diagnostic services

Comprehensive dental	Not covered

Endodontics

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

Extractions

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	50% coinsurance

Non-routine services

Comprehensive dental	Not covered

Periodontics

Comprehensive dental	Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	50% coinsurance

Restorative services

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Freedom Blue PPO Valor (PPO) requires you to live in that plan’s service area. The service area is listed below:

State:	Delaware Medicare
County:	Kent County MA Plans New Castle County MA Plans Sussex County MA Plans

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How much does Freedom Blue PPO Valor (PPO) cost?

Highmark Inc. charges a $0 monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage. The premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Freedom Blue PPO Valor (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Freedom Blue PPO Valor (PPO) by Highmark Inc. MOOP is $6,000. Once you spend $6,000 you will pay nothing for Part A or Part B covered services.

What type of plan is Freedom Blue PPO Valor (PPO)?

Freedom Blue PPO Valor (PPO) is a Local PPO *. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.

Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.