Freedom Nation (PPO)
Low-cost PPO provides a comprehensive network of providers and hospitals. Pay in-network for all plan covered services when you receive care outside of WNY with the Medicare Advantage Network Sharing Program.
standard
Freedom Nation (PPO)
standard
PRIMARY/SPECIALTY
$5/$35
DRUG DEDUCTIBLES
Tier 1-2: $0, Tier 3 - Tier 5: $290
INPATIENT HOSPITAL
$370 per day for days 1-5,
$1,850 OOP Max per year
Freedom Nation (PPO) Plan Details
Primary Care Doctor/Specialist
| Primary Care Doctor | Specialist |
|---|---|
| $5 | $35 |
Use our 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; $290 Tiers 3-5 |
| Part D Prescriptions: | Preferred Pharmacy | Standard Pharmacy |
|---|---|---|
| Tier 1 | $0 | $5 |
| Tier 2 | $12 | $17 |
| Tier 3 | $42 | $47 |
| Tier 4 | $94 | $100 |
| Tier 5 | 28% | 28% |
$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 Infomation
The 2022 Medicare Formulary includes a list of prescription care drugs covered by a prescription drug plan.
Surgery & Treatment
| Inpatient hospital | $370/day, days 1-5 / $1,850 OOP max per year |
| Outpatient hospital | $400 |
| Ambulatory surgery | $300 |
| X-rays | $50 |
| Advanced radiology | $200 |
| Lab | $5 |
Preventive Dental
All of our plans include preventive dental coverage:
- Routine cleanings/oral exams - twice per year ($10 copay per service).
- X-rays - four bitewing or one full-month X-ray per year ($10 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 | $12 | 50% coinsurance | $500 |
| Enhanced | $25 | 50% coinsurance | $1,000 |
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 | $188/day |
| Hearing aid (specific models)* | $699 or $999/unit |
| In-network out-of-pocket maximum | $7,550 |
*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).
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.
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Highmark Blue Cross Blue Shield of Western New York (Highmark BCBSWNY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BCBSWNY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BCBSWNY 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