Freedom Premier (HMO)
Freedom Premier (HMO)
$0 Tiers 1-2; $100 Tiers 3-5
$295 per day for days 1-7, $1,180 OOP Max per year
Freedom Premier (HMO) Plan Details
Primary Care Doctor/Specialist
|Primary Care Doctor||Specialist|
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.
Part D Prescription Drugs
|Drug Deductibles||$0 Tiers 1-2; $100 Tiers 3-5|
|Part D Prescriptions:||Preferred Pharmacy||Standard Pharmacy|
$0 Tier 1 Generics with Convenient Home Delivery
$0 copay for a 90-day supply of Tier 1 preferred generic medications delivered for free through Express Scripts® mail order during the initial coverage stage.
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.
Surgery & Treatment
|Inpatient hospital||$295/day, days 1-4; $1,180 max out-of-pocket per year|
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|
Note: Preventive services do not count toward the annual max allowance for dental.
|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||$6,700|
*Our plans cover one routine hearing exam per year with a TruHearing® provider. Cost shares may apply. 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).
This past January, the Centers for Medicare & Medicaid Services (CMS) added acupuncture as a covered benefit for Medicare patients with chronic low back pain. According to CMS, coverage will include "up to 12 sessions in 90 days with an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement." Treatment must also be recommended and supervised by a doctor.
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)
Content last updated October 15, 2020