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Freedom Blue PPO Choice Deluxe (PPO) - H8166-004-000
$13.00
Monthly Premium
Freedom Blue PPO Choice Deluxe (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H8166-004-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$13.00
Monthly Premium
Delaware Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Delaware Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $13.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $6,000.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30 |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: $350 per day for days 1 to 5 $0 per day for days 6 to 90 Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care. |
| Urgent care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $50 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $250 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250 Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. Air Ambulance: Copayment for Air Ambulance Services $250 Prior Authorization Required for Air Ambulance Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. |
Health Care Services and Medical Supplies
Freedom Blue PPO Choice Deluxe (PPO) covers a range of additional benefits. Learn more about Freedom Blue PPO Choice Deluxe (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Glucometers, test strips, lancets, control solution, replacement batteries, platforms, lens shield, and non-invasive vagus nerve stimulator are supplied at a $0 copay. All other Medicare covered Diabetic Supplies have a 20% coinsurance.Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to Abbott and LifeScan. Continuous glucose monitors, sensors and transmitters dispensed via retail or mail order pharmacy are limited to Abbott and Dexcom. All other desired brands will need to be obtained via an exception process or from a Durable Medical Equipment (DME) supplier. |
| Durable medical equipment (DME) | Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 30% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $50 Copayment for Medicare Covered Lab Services $50 Copayment for Medicare Covered Diagnostic Radiological Services $300 Copayment for Medicare Covered Therapeutic Radiological Services $75 Copayment for Medicare Covered Outpatient X-Ray Services $45 The minimum copayment applies for Medicare-covered diagnostic procedures/tests and lab services provided at free standing labs and physicians offices. The maximum copayment applies for Medicare-covered diagnostic procedures/tests and lab services at an outpatient hospital facility. |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: $500 per day for days 1 to 3 $0 per day for days 4 to 90 Private accommodations will be covered when medically necessary. Inpatient substance abuse is subject to the same cost sharing as Inpatient Psychiatric Hospital. |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 |
| Outpatient services/surgery | Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $400 Copayment for Medicare Covered Ambulatory Surgical Center Services $300 Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment. |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0 The OTC benefit is part of a combined benefits/reduction in cost sharing package that includes dental/vision/hearing/OTC up to $630 maximum administered through a debit card. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30 Copayment for Routine Foot Care $30
|
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Private accommodations will be covered when medically necessary. |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Dental: Copayment for Office Visit $30 Non-Medicare Covered Preventive Dental:
Non-Medicare Covered Comprehensive Dental: Coinsurance for Restorative services 40%
Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Dental $30 Non-Medicare Covered Preventive Dental: Non-Medicare Covered Comprehensive Dental: |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $30 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $350 every year A $200 benefit maximum applies to upgrades to post cataract surgery eyewear that are not medically necessary. Benefit maximum is available following cataract surgery once per operated eye. For non-post cataract eyewear, the Plan offers additional coverage for non-Medicare covered (routine) eyewear. Routine eyewear benefit is limited to one pair of eyeglass frames, including one pair of eyeglass lenses or contact lenses every calendar year. Standard eyeglass frames, standard plastic eyeglass lenses, or standard contact lenses are covered in full at participating network provider locations. A $150 benefit maximum is available towards the purchase of non-standard eyeglass frames or towards the purchase of non-standard contact lenses. Members must pay the difference between benefit maximums and provider charge. Out-of-Network: Eye Exams: Copayment for Medicare Covered Benefits $30 Copayment for Routine Eye Exams $50
Eyewear: Copayment for Medicare-Covered Benefits $0 |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $30 |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing Delaware Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Delaware that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Delaware Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.