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Freedom Basic (PPO)

NEW! Enjoy comprehensive medical and drug coverage, additional benefits, and get $50 back every month. This unique benefit comes with our Freedom Basic (PPO) plan and puts $50 back in your Social Security check every month.*

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Freedom Basic (PPO)

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Enjoy comprehensive medical and drug coverage, additional benefits, and get $50 back every month.

PRIMARY/SPECIALTY
$15/$46

DRUG DEDUCTIBLES
$0 Tiers 1–2; $350 Tiers 3–5

INPATIENT HOSPITAL
$400 per day for days 1-5, $2,000 OOP Max per year

MONTHLY PREMIUM

$0

MONTHLY PREMIUM

$0

Freedom Basic (PPO) Plan Details

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Primary Care Doctor/Specialist

Primary Care Doctor Specialist
$15 $46
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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; $350 Tiers 3-5
Part D Prescriptions: Preferred Pharmacy Standard Pharmacy
Tier 1 $2 $7
Tier 2 $14 $19
Tier 3 $42 $47
Tier 4 $94 $100
Tier 5 27% 27%

$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 2022 Medicare Formulary includes a list of prescription care drugs covered by a prescription drug plan.

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Surgery & Treatment

 
 
Inpatient hospital $400/day, days 1-4; $2,000 OOP max per year
Outpatient hospital $475
Ambulatory surgery $425
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 - once 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 $188/day
Hearing aid (specific models) Not Covered
In-network out-of-pocket maximum $7,550
Combined in and out-of-network maximum $11,300

Medicare Questions?

We're here to help.

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

*Beneficiaries are eligible for a Part B monthly premium giveback if they do not receive Medicaid or anyother assistance paying their Part B premium. Beneficiaries must continue paying their Part B premium.

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

Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BSNENY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark 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 1, 2021