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Freedom Value (HMO)

 

New for 2020! New Blue Total Health Package

Live a healthy lifestyle with our additional BlueShield benefits and preventive services included in your Medicare Advantage plan.

Freedom Value (HMO)

Your Estimated Monthly Premium $0.00

Doctors

Primary Care Doctor Specialist
$0 $40
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Use our new Find a Doctor tool to discover if your doctor, specialist, or facility are in-network.

If they are not in-network, you can search to find one that is in our network of providers. 

Prescription Drugs

Drug Deductibles  $0 Tiers 1 - 2; $350 Tiers 3 - 5
Part D Prescriptions: Preferred Pharmacy Standard Pharmacy
Tier 1 $3 $9
Tier 2 $10 $15
Tier 3 $42 $47
Tier 4 $94 $100
Tier 5 26% 26%

The Medicare Part D Coverage Gap
The 'coverage gap' or 'donut hole' is a Part D drug coverage stage that changes what you pay for prescriptions. You may not end up in the coverage gap each year, but you should be aware of how it works.

Prescription Drug Infomation
The 2020 Medicare Formulary includes a list of prescription care drugs covered by a prescription drug plan.

Surgery & Treatment

 
 
Inpatient hospital $370 per day, days 1-5 / $1,850 out-of-pocket max per year
Outpatient hospital $550
Ambulatory surgery $450
X-rays $50
Advanced radiology $200
Lab copayment $10

Dental Coverage

Preventive Dental

All our plans include preventive dental coverage:

  • Routine cleanings/oral exams - twice per year ($15 copay per service).
  • X-rays - four bitewing or one full-month X-ray per year ($15 copay per service).

Optional Supplemental Dental is also available:
You may add Dental Care with the following optional supplemental benefits (no network - see any dentist):

 
Premium Diagnostic and Restorative Service Cost Annual Max Allowance
Basic $13 50% coinsurance $500
Enhanced $24 50% coinsurance $1,000

Note: Preventive services do not count toward the annual max allowance for dental.

Plan Highlights

 
 
World coverage for emergency and urgent care $90/$65
Part B diabetes supplies and monitors $0
Skilled nursing facility days 1-20 $0
Skilled nursing facility days 21-100 $178.00/day
Hearing aid (specific models)* $699 or $999/unit
In-network out-of-pocket maximum $6,700

*Our plans cover one routine hearing exam per year with a TruHearing® provider. Please call TruHearing to verify your benefit and schedule a hearing exam. Hearing aid $699 or $999/unit (one per ear, per year, specific models).

New Blue Total Health Package

Our Blue Total Health package provides you with the additional benefits and preventive services you want and need to help you live a healthy lifestyle. This exclusive benefits package includes:  

Preventive dental

Preventive dental coverage includes reimbursement for up to two cleanings, two exams, and one set of X-rays annually1. This benefit requires no network and can be used at any dental provider.

  • $15 copay per service

Over-the-counter (OTC)

Up to $100 annual allowance for over-the-counter drugs and supplies with convenient home delivery. Choose from hundreds of items from an online shop or catalog including vitamins, allergy care, first aid and supports and braces.2

Vision3

  • $100 annual allowance on frames, lenses, and contacts through an EyeMed provider
  • $25 annual routine eye exam through an EyeMed provider

Hearing

Save thousands on hearing aids through TruHearing.

  • $699 or $999 per unit4
  • $45 annual routine hearing exam through a TruHearing provider

Fitness

SilverSneakers® no-cost fitness benefit with access to 16,000+ fitness locations nationwide.

Rewards for preventive services

Earn up to $60 for annual preventive services including annual wellness visit, colon cancer screening, and breast cancer screening.5 Up to $60 total or one $20 Prepaid Card per service.

Low- or no-cost vaccines

  • $0 copay for preventive vaccines including flu, pneumonia, and hepatitis
  • Coverage for shingles vaccine with Tier 1 copay (copay varies by plan)

Part B diabetic monitoring supplies

  • $0 Part B diabetic monitoring supplies including lancets, glucose monitors, and test strips

Unless otherwise noted, costs shown are for services received in-network.

Contracts and Additional Resources

Medicare Questions?

We're here to help.

1-833-735-4512 (TTY 711)
Oct. 1 - Dec. 31, 8 a.m. - 8 p.m., 7 days a week
Jan. 1 - Sept. 30, 8 a.m. - 8 p.m., Monday - Friday

*If you need a different format, please view our Multi-Language Interpreter Services.

BlueShield of Northeastern New York (BSNENY) is a division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association. BSNENY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711). 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711)

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Content last updated October 15, 2019.