Freedom Blue PPO Valor (PPO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Highmark Blue Cross Blue Shield
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: 40% coinsurance
Out-of-network: 40% coinsurance
Out-of-network: $0 copay
Emergency Room
$130 copay
Ambulance Coverage
In-network: $425 copay
Out-of-network: $425 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$10 copay
Out-of-network: 40% coinsurance
Lab services:
In-network: $0-$10 copay
Out-of-network: 40% coinsurance
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $225 copay
Out-of-network: 40% coinsurance
Outpatient x-rays:
In-network: $20 copay
Out-of-network: 40% coinsurance
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$275 per stay
Out-of-network:
$395 per stay
Outpatient hospital coverage:
In-network: $245 copay
Out-of-network: $375 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $15 copay
Out-of-network: 40% coinsurance
Urgent Care Coverage
$130 copay
Skilled Nursing Facility (SNF)
In-network:
Tier 1
$0 per day for days 1-20
$218 per day for days 21-100
Out-of-network:
30% per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $5 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy with a psychiatrist:
In-network: $5 copay
Out-of-network: 40% coinsurance
Outpatient group therapy visits:
In-network: $5 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy visit:
In-network: $5 copay
Out-of-network: 40% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: 30% coinsurance
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: 30% coinsurance
Dental x-rays:
In-network: $0 copay
Out-of-network: 30% coinsurance
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $50 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
In-network: $699-$999 copay
Out-of-network: $0 copay
Additional Added Benefits
Plan Links
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