Blue Medicare Freedom+ (PPO)
Blue Medicare Freedom+ (PPO) H3404-004 Plan Details
Blue Medicare Freedom+ (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H3404-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Blue Medicare Freedom+ (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H3404-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Blue Medicare Freedom+ (PPO) H3404-004 Plan Details
Blue Medicare Freedom+ (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H3404-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
North Carolina Counties Served
Iredell
Alamance
Davidson
Forsyth
Davie
Yadkin
Chatham
Surry
Pasquotank
Duplin
Rowan
Wilkes
Vance
Stokes
Anson
Randolph
Rockingham
Northampton
Polk
Montgomery
Moore
Caswell
Guilford
Harnett
Orange
Lee
Durham
Person
Richmond
Johnston
Wake
Wayne
Wilson
Franklin
Warren
Nash
Transylvania
Graham
Gaston
Hyde
Edgecombe
Hertford
Chowan
Beaufort
Martin
Halifax
Gates
Greene
Dare
Perquimans
Camden
Stanly
Jones
Currituck
Lincoln
Tyrrell
Washington
Catawba
Burke
Cleveland
Pender
Rutherford
Mecklenburg
Cabarrus
Mcdowell
Brunswick
Pamlico
Union
Swain
Sampson
Scotland
Hoke
New Hanover
Cumberland
Robeson
Columbus
Bladen
Ashe
Yancey
Lenoir
Caldwell
Alexander
Jackson
Avery
Watauga
Alleghany
Buncombe
Henderson
Cherokee
Mitchell
Haywood
Clay
Madison
Macon
Granville
Bertie
Carteret
Pitt
Onslow
Craven
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $9350 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Coinsurance for Primary Care Office Visit 20% Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 40% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 20% Specialist coinsurance also applies to acupuncture for chronic Low Back Pain (cLBP) Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 40% Specialist coinsurance also applies to acupuncture for chronic Low Back Pain (cLBP) |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $2185 days 1-90 $816 days 91-150 Prior Authorization Required for Acute Hospital Services Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 40% Prior authorization required |
| Urgent Care | Copayment for Urgent Care $45 |
| Emergency Room Visit | Copayment for Emergency Care $100 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 48 hours |
| Ambulance Transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance Prior authorization required Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 40% Coinsurance for Medicare Covered Ambulance Services - Air 40% |
Health Care Services and Medical Supplies
Blue Medicare Freedom+ (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $15 Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Coinsurance for Medicare-covered Diabetic Supplies 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 40% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Coinsurance for Medicare-covered Lab Services 20% Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered X-Ray Services 20% Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $2036 days 1-90 $816 days 91-150 Prior Authorization Required for Psychiatric Hospital Services Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 40% Prior authorization required |
| Mental Health Outpatient Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 20% Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 20% Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
| Outpatient Substance Abuse Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0 Quitline Program for smoking cessation, the following is available at no cost: 12-wk regimen of combination therapy NRT for up to 2 quit attempts per year NRT (available for 2 quit attempts, total 24 weeks) Monotherapy (1 type of NRT) Gum = 12 wks = 2 boxes shipment 1, 2 boxes shipment 2, 1 box shipment 3 Lozenge = 12 wks = 4 boxes shipment 1, 1 box shipment 2, 1 box shipment 3 Patch = 1 shipment (4 wk supply of 28 patches)* CNRT=combination NRT Patch + Gum 12 wks = 1 patch + 2 boxes gum shipment 1, 1 patch + 1 box gum shipment 2, 1 patch shipment 3 Patch + Lozenge 12 wks = 1 patch + 2 boxes lozenge shipment 1, 1 patch + 1 box lozenge shipment 2, 1 patch shipment 3 Out-of-Network: Non-Medicare Covered Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0 |
| Podiatry Services | In-Network: Coinsurance for Medicare-Covered Podiatry Services 20% Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 60 $0 per day for days 61 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Medicare Covered Preventive Dental: Coinsurance for Office Visit 20% Prior Authorization Required for Medicare Covered Preventive Dental Prior authorization required Out-of-Network: Medicare Covered Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 40% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 20% Medicare Covered Eyewear $0 Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Coinsurance for Medicare Covered Eyewear 40% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 20% Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 40% |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
