Freedom Blue PPO Distinct (PPO)
H8166 - 004 - 0
(4 / 5)
Freedom Blue PPO Distinct (PPO) is a Medicare Advantage Plan by Highmark Blue Cross Blue Shield.
This page features plan details for 2024 Freedom Blue PPO Distinct (PPO) H8166 – 004 – 0 available in Delaware.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Freedom Blue PPO Distinct (PPO) is offered in the following locations.
Plan Overview
Freedom Blue PPO Distinct (PPO) offers the following coverage and cost-sharing.
| Insurer: | Highmark Blue Cross Blue Shield |
| Health Plan Deductible: | |
| MOOP: | $6,000.00 |
| Drugs Covered: | Yes |
Ready to sign up for Freedom Blue PPO Distinct (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
Premium Breakdown
Freedom Blue PPO Distinct (PPO) has a monthly premium of $25.00. 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 | $25.00 | $0.00 | $ |
- 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 Blue PPO Distinct (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| 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 |
|---|---|
| $25.00 | $ |
Initial Coverage Phase
After you pay your $0.00 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 | ||
| 2 (Generic) | $5.00 copay | $15.00 copay | ||
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
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 | $21.00 copay |
| 2 (Generic) | $15.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
| 3 (Preferred Brand) | $141.00 copay | $141.00 copay | $120.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | $275.00 copay | $300.00 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 Blue PPO Distinct (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $9,550 In and Out-of-network $6,000 In-network |
| No |
| In-network | No |
| In-network | $250 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $300 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $20 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $20 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-10 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $50 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0-10 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $50 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $195 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $300 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $15 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $20 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $20 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Office visit | $0.00 (Authorization is not required.) (Referral is not required.) |
| out-of-network Office visit | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| Oral exam | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Non-routine services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $50 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $50 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $50 copay (Authorization is required.) (Referral is not required.) |
| In-network | $250 copay (Not applicable.) (Not applicable.) |
| out-of-network | $250 copay or 30% coinsurance (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $20 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network Routine foot care | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 30% 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) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 30% 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 | 30% 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 | 30% 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 | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $350 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $350 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $425 per day for days 1 through 3 $0 per day for days 4 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $500 per day for days 1 through 3 $0 per day for days 4 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $45 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $45 copay (Authorization is 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 | 30% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Freedom Blue PPO Distinct (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
Table of Contents
Need more information on Freedom Blue PPO Distinct (PPO)? See 2025 Freedom Blue PPO Distinct (PPO) at MedicareAdvantageRX.com.
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