Freedom Basic (PPO)
H5526 - 022 - 0
(4 / 5)
Freedom Basic (PPO) is a Medicare Advantage Plan by Highmark Blue Cross Blue Shield or Highmark Blue Shield.
This page features plan details for 2024 Freedom Basic (PPO) H5526 – 022 – 0 available in Northeastern New York.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Freedom Basic (PPO) is offered in the following locations.
Plan Overview
Freedom Basic (PPO) offers the following coverage and cost-sharing.
| Insurer: | Highmark Blue Cross Blue Shield or Highmark Blue Shield |
| Health Plan Deductible: | $0.00 |
| MOOP: | $12,450 In and Out-of-network $8,300 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $350.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Freedom Basic (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Freedom Basic (PPO) qualifies for a monthly Medicare Give Back Benefit of $57.00.
| Premium Reduction: | $57.00 |
Premium Breakdown
Freedom Basic (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $57.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Freedom Basic (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $350.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $0.00 | $ |
Initial Coverage Phase
After you pay your $350.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $7.00 copay | $0.00 copay | $7.00 copay |
| 2 (Generic) | $14.00 copay | $19.00 copay | $14.00 copay | $19.00 copay |
| 3 (Preferred Brand) | $42.00 copay | $47.00 copay | $42.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $94.00 copay | $100.00 copay | $94.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 27% | 27% | 27% | 27% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $21.00 copay | $0.00 copay | $17.50 copay |
| 2 (Generic) | $42.00 copay | $57.00 copay | $35.00 copay | $47.50 copay |
| 3 (Preferred Brand) | $126.00 copay | $141.00 copay | $105.00 copay | $117.50 copay |
| 4 (Non-Preferred Drug) | $282.00 copay | $300.00 copay | $235.00 copay | $250.00 copay |
| 5 (Specialty Tier) |
Gap Coverage Phase
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
Freedom Basic (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $12,450 In and Out-of-network $8,300 In-network |
| No |
| In-network | No |
| In-network | $475 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 50% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0-10 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | 50% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | 50% coinsurance per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $50 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $10 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $10 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $200 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $50 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Oral exam | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Non-routine services | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic services | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Restorative services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Restorative services | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Endodontics | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Endodontics | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Periodontics | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Periodontics | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Extractions | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Extractions | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | $20 copay or 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Routine eye exam | $25 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $305 copay (Not applicable.) (Not applicable.) |
| out-of-network | $305 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Routine foot care | $40 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 50% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 50% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 50% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 50% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 50% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 50% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $400 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | 50% per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $395 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 50% per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 50% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Freedom Basic (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
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