Freedom Blue PPO Basic (PPO)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: No

Comprehensive Dental

• Adjunctive General Services
  • In-Network: No Coins – No Co pay
  • Out-of-Network: 30% Coins – No Copay

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – – Copay
  • Out-of-Network: 30% Coins – No Copay
• Oral Exams
  • In-Network: No Coins – – Copay
  • Out-of-Network: 30% Coins – No Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – – Copay
  • Out-of-Network: 30% Coins – No Copay

Diagnostic procedures/lab services/imaging

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

Doctor visits

• Primary
  • In-Network: $0 copay
  • Out-of-Network: $0 copay
• Specialist
  • In-Network: $35 copay per visit
  • Out-of-Network: $35 copay per visit

Emergency care/Urgent care

• Urgent care
  • $50 copay per visit (always covered)
• Emergency
  • $125 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • Out-of-Network: $35 copay
  • In-Network: $35 copay
• Routine foot care
  • In-Network: $35 copay (Limits Apply)

Ground ambulance

• • In-Network: $125 copay
  • Out-of-Network: $125 copay or 30% coinsurance

Health plan deductible

• • $0

Hearing

• Fitting/evaluation
  • Not covered
• Medicare-Covered Hearing Exam
  • Out-of-Network: $35 copay
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • In-Network: $35 copay
• Hearing aids
  • In-Network: $599-899 copay (Limits Apply)
  • Out-of-Network: $0 copay (Limits Apply)

Inpatient hospital coverage

• • Out-of-Network: $340 per stay (Authorization Required)
  • In-Network: $340 per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $8,950 In and Out-of-network
    $5,900 In-network

Medical equipment/supplies

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

Medicare Part B drugs

• Other Part B drugs
  • In-Network: 0-20% coinsurance (Authorization Required)
• Chemotherapy
  • In-Network: 0-20% coinsurance (Authorization Required)
• Other Part B drugs
  • Out-of-Network: 30% coinsurance (Authorization Required)
• Chemotherapy
  • Out-of-Network: 30% coinsurance (Authorization Required)

Mental health services

• Inpatient hospital – psychiatric
  • In-Network: $340 per stay (Authorization Required)
  • Out-of-Network: $340 per stay (Authorization Required)
• Outpatient group therapy visit with a psychiatrist
  • Out-of-Network: $35 copay
• Outpatient individual therapy visit
  • In-Network: $35 copay
• Outpatient group therapy visit
  • Out-of-Network: $35 copay
• Outpatient individual therapy visit
  • Out-of-Network: $35 copay
• Outpatient individual therapy visit with a psychiatrist
  • In-Network: $35 copay
  • Out-of-Network: $35 copay
• Outpatient group therapy visit
  • In-Network: $35 copay
• Outpatient group therapy visit with a psychiatrist
  • In-Network: $35 copay

Optional supplemental benefits

• • No

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • Out-of-Network: $200 copay per visit (Authorization Required)
  • In-Network: $200 copay per visit (Authorization Required)

Preventive care

• • Out-of-Network: $0 copay
  • In-Network: $0 copay

Rehabilitation services

• Occupational therapy visit
  • In-Network: $35 copay (Authorization Required)
• Physical therapy and speech and language therapy visit
  • Out-of-Network: $35 copay (Authorization Required)
• Occupational therapy visit
  • Out-of-Network: $35 copay (Authorization Required)
• Physical therapy and speech and language therapy visit
  • In-Network: $35 copay (Authorization Required)

Skilled Nursing Facility

• • Out-of-Network: 30% per stay (Authorization Required)
  • In-Network: $0 per day for days 1 through 20
    $214 per day for days 21 through 100 (Authorization Required)

Transportation

• • Out-of-Network: 30% coinsurance (Limits Apply, Authorization Required)
  • In-Network: $0 copay (Limits Apply, Authorization Required)

Vision

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

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

• • Covered