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Freedom Nation (PPO)  
 

New $0 premium  PPO provides a comprehensive network of providers and hospitals.  Pay in-network for all plan covered services when you receive care outside of the area with the Blue Card Network Sharing Program. 

Freedom Nation (PPO)

New for 2021! $0 premium PPO provides a comprehensive network of providers and hospitals.

PRIMARY/SPECIALTY
$5/$45

DRUG DEDUCTIBLES
$0 Tiers 1-2; $375 Tiers 3-5

INPATIENT HOSPITAL
$375 per day for days 1-5, $1,875 OOP Max per year

MONTHLY PREMIUM

$0

MONTHLY PREMIUM

$0

Freedom Nation (PPO) Plan Details

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Primary Care Doctor/Specialist

Primary Care Doctor Specialist
$5 $45
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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. 

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Part D Prescription Drugs

 
 
Drug Deductibles $0 Tiers 1-2; $375 Tiers 3-5
Part D Prescriptions: Preferred Pharmacy Standard Pharmacy
Tier 1 $3 $8
Tier 2 $12 $17
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 Information
The 2021 Medicare Formulary includes a list of prescription care drugs covered by a prescription drug plan.

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Surgery & Treatment

 
 
Inpatient hospital $375 per day for days 1-5, $1,875 OOP Max per year
Outpatient hospital $375
Ambulatory surgery $275
X-rays $50
Advanced radiology $250
Lab copayment $10
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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.

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Plan Highlights

 
 
Worldwide coverage for emergency and urgent care $90 Emergency care; $65 Urgent care
Part B diabetes supplies and monitors $0
Skilled nursing facility days 1-20 $0
Skilled nursing facility days 21-100 $184/day
Hearing aid (specific models)* $699 or $999/unit
In-network out-of-pocket maximum $7,550

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, 2020