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2011 Medicare Advantage Plan Benefit Details for the FreedomBlue PPO Value (PPO) - H5106-018-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Medicare Advantage Plan Details
Medicare Plan Name:FreedomBlue PPO Value (PPO)
Location:Harrison, West Virginia     Click to see other locations
Plan ID:H5106 - 018 - 0     Click to see other plans
Member Services:1-888-459-4020 TTY users 1-800-855-1155
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the FreedomBlue PPO Value (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$70.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:Local PPO *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,400
Number of Members enrolled in this plan in (H5106 - 018):131 members
— Plan Premium Details —
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Cost **
Premium and Other Important Information
$70.00 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
This plan covers all Medicare-covered preventive services with zero cost sharing.
$3 400 out-of-pocket limit.
This limit includes only Medicare-covered services.
$500 yearly deductible. Contact the plan for services that apply.
$5 100 out-of-pocket limit.
In-Network: This limit includes only Medicare-covered services.
Out-Of-Network: This limit includes only Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
Plan covers you when you travel in the U.S.
** Extra Benefits **
Prescription Drugs
Most drugs not covered.
0% to 20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
0% to 30% of the cost for Part B drugs out-of-network.
This plan does not offer prescription drug coverage.
Physical Exams
$0 copay for routine exams.
Limited to 1 exam(s) every year.
Separate Office Visit cost sharing of $15 to $35 may apply.
$0 copay for routine exams.
Vision Services
$0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery
  • up to 1 pair(s) of contacts every two years
  • up to 1 pair(s) of lenses every two years
  • up to 1 frame(s) every two years
  • $0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $35 copay for up to 1 routine eye exam(s) every year
    • Separate Office Visit cost sharing of $15 to $35 may apply.
    $100 plan coverage limit for contact lenses every two years.
    $100 plan coverage limit for eye glass frames every two years.
    Plan offers additional vision benefits.
    0% to 30% of the cost for eye exams.
    30% of the cost for eye wear.
    Dental Services
    Authorization rules may apply.
    In general preventive dental benefits (such as cleaning) not covered.
    $35 to $250 copay for Medicare-covered dental benefits.
    Separate Office Visit cost sharing of $15 to $35 may apply.
    30% of the cost for comprehensive dental benefits.
    ** Important Information **
    Premium and Other Important Information
    $70.00 monthly plan premium in addition to your monthly Medicare Part B premium.
    Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
    This plan covers all Medicare-covered preventive services with zero cost sharing.
    $3 400 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    $500 yearly deductible. Contact the plan for services that apply.
    $5 100 out-of-pocket limit.
    In-Network: This limit includes only Medicare-covered services.
    Out-Of-Network: This limit includes only Medicare-covered services.
    Doctor and Hospital Choice
    No referral required for network doctors specialists and hospitals.
    You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
    Plan covers you when you travel in the U.S.
    ** Inpatient Care **
    Inpatient Hospital Care (Acute)
    No limit to the number of days covered by the plan each benefit period.
    $250 copay for each Medicare-covered hospital stay
    $0 copay for additional hospital days
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    30% of the cost for each hospital stay.
    Inpatient Mental Health Care
    You get up to 190 days in a Psychiatric Hospital in a lifetime.
    $250 copay for each Medicare-covered hospital stay.
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    30% of the cost for each hospital stay.
    Skilled Nursing Facility (SNF)
    Authorization rules may apply.
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For SNF stays:
    Days 1 - 15: $0 copay per day
    Days 16 - 75: $50 copay per day
    Days 76 - 100: $0 copay per day
    30% of the cost for each SNF stay.
    Home Health Care
    Authorization rules may apply.
    $0 copay for Medicare-covered home health visits.
    30% for home health visits.
    Hospice
    You must get care from a Medicare-certified hospice.
    ** Outpatient Care **
    Doctor Office Visits
    See 'Welcome to Medicare; and Annual Wellness Visit' for more information.
    $15 copay for each primary care doctor visit for Medicare-covered benefits.
    $35 copay for each in-area network urgent care Medicare-covered visit.
    $35 copay for each specialist visit for Medicare-covered benefits.
    30% for each primary care doctor visit.
    30% for each specialist visit.
    Chiropractic Services
    $35 copay for each Medicare-covered visit.
    Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
    30% of the cost for chiropractic benefits.
    Podiatry Services
    $35 copay for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    30% of the cost for podiatry benefits.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $35 copay for each Medicare-covered individual or group therapy visit.
    30% of the cost for Mental Health benefits.
    30% of the cost for Mental Health benefits with a psychiatrist.
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $35 copay for Medicare-covered individual or group visits.
    30% of the cost for outpatient substance abuse benefits.
    Outpatient Hospital Services
    Authorization rules may apply.
    $250 copay for each Medicare-covered ambulatory surgical center visit.
    $250 copay for each Medicare-covered outpatient hospital facility visit.
    30% of the cost for ambulatory surgical center benefits.
    30% of the cost for outpatient hospital facility benefits.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits.
    Worldwide coverage.
    If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    $35 copay for Medicare-covered Occupational Therapy visits.
    $35 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
    $0 copay for Medicare-covered Cardiac Rehab services.
    30% of the cost for Occupational Therapy benefits.
    30% of the cost for Physical and/or Speech and Language Therapy visits.
    30% of the cost for Cardiac Rehab services.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    0% to 15% of the cost for Medicare-covered items.
    0% to 50% of the cost for durable medical equipment.
    Prosthetic Devices
    Authorization rules may apply.
    15% of the cost for Medicare-covered items.
    50% of the cost for prosthetic devices.
    Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
    Authorization rules may apply.
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    0% to 15% of the cost for Diabetes supplies.
    Separate Office Visit cost sharing of $15 to $35 may apply.
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    50% of the cost for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement
    Separate Office Visit cost sharing of $15 to $35 may apply.
    $0 copay for Medicare-covered bone mass measurement.
    Colorectal Screening Exams
    $0 copay for Medicare-covered colorectal screenings.
    Separate Office Visit cost sharing of $15 to $35 may apply.
    $0 copay for colorectal screenings.
    Immunizations
    $0 copay for Flu and Pneumonia vaccines.
    $0 copay for Hepatitis B vaccine.
    No referral needed for Flu and pneumonia vaccines.
    $0 copay for immunizations.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams
  • up to 1 additional pap smear(s) and pelvic exam(s) every year
    • Separate Office Visit cost sharing of $15 to $35 may apply.
    $0 copay for pap smears and pelvic exams.
    Prostate Cancer Screening Exams
    $0 copay for
    • Medicare-covered prostate cancer screening
    Separate Office Visit cost sharing of $15 to $35 may apply.
    $0 copay for prostate cancer screening.
    ** Additional Benefits **
    Dialysis
    $0 copay for renal dialysis
    $0 copay for Nutrition Therapy for End-Stage Renal Disease
    0% to 30% of the cost for renal dialysis.
    $0 copay for Nutrition Therapy for End-Stage Renal Disease.
    Prescription Drugs
    Most drugs not covered.
    0% to 20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
    0% to 30% of the cost for Part B drugs out-of-network.
    This plan does not offer prescription drug coverage.
    Dental Services
    Authorization rules may apply.
    In general preventive dental benefits (such as cleaning) not covered.
    $35 to $250 copay for Medicare-covered dental benefits.
    Separate Office Visit cost sharing of $15 to $35 may apply.
    30% of the cost for comprehensive dental benefits.
    Hearing Services
    $0 copay for hearing aids.
  • $35 copay for Medicare-covered diagnostic hearing exams
  • $35 copay for up to 1 routine hearing test(s) every year
    • $500 plan coverage limit for hearing aids every three years.
    30% of the cost for hearing exams.
    $0 copay for hearing aids.
    Vision Services
    $0 copay for
    • one pair of eyeglasses or contact lenses after cataract surgery
  • up to 1 pair(s) of contacts every two years
  • up to 1 pair(s) of lenses every two years
  • up to 1 frame(s) every two years
  • $0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $35 copay for up to 1 routine eye exam(s) every year
    • Separate Office Visit cost sharing of $15 to $35 may apply.
    $100 plan coverage limit for contact lenses every two years.
    $100 plan coverage limit for eye glass frames every two years.
    Plan offers additional vision benefits.
    0% to 30% of the cost for eye exams.
    30% of the cost for eye wear.
    Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s) every year.
    Separate Office Visit cost sharing of $15 to $35 may apply.
    $0 copay for routine exams.
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Health Club Membership/Fitness Classes
  • Other Wellness Benefits
    • $0 copay for each Medicare-covered smoking cessation counseling session.
    $0 copay for each Medicare-covered HIV screening.
    HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.
    0% to 50% of the cost for Health and Wellness services.
    Transportation
    $40 copay for one-way trips to Plan-approved location.
    50% of the cost for transportation.
    Acupuncture
    This plan does not cover Acupuncture.




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