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Freedom Value (HMO)

 

Freedom Value (HMO)

PRIMARY/SPECIALTY
$0/$40

DRUG DEDUCTIBLES
$0 Tiers 1-2; $295 Tiers 3-5

INPATIENT HOSPITAL
$370 per day for days 1-5,
$1,850 OOP Max per year

MONTHLY PREMIUM

$0

MONTHLY PREMIUM

$0

Freedom Value (HMO) Plan Details

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Primary Care Doctor/Specialist

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. 

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Part D Prescription Drugs

Drug Deductibles  $0 Tiers 1 - 2; $295 Tiers 3 - 5
Part D Prescriptions: Preferred Pharmacy Standard Pharmacy
Tier 1 $2 $7
Tier 2 $10 $15
Tier 3 $42 $47
Tier 4 $94 $100
Tier 5 27% 27%
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$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 the 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, just in case. 

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 $370 per day, days 1-5 / $1,850 out-of-pocket max per year
Outpatient hospital $350
Ambulatory surgery $250
X-rays $50
Advanced radiology $200
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
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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 $184.00/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