Freedom Nation Prestige (PPO)
Freedom Nation Prestige (PPO) H5526-027 Plan Details
Freedom Nation Prestige (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5526-027
HelpAdvisor Editorial Team analysis of data from the 2024 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.
$52.00
Monthly Premium
Freedom Nation Prestige (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H5526-027
HelpAdvisor Editorial Team analysis of data from the 2024 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.
New York Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6750 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 50% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $10 Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 50% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $305 per day for days 1 to 6 $0 per day for days 7 to 90 Maximum out of Pocket $1,830 every year Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 50% |
| Urgent Care | Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $55 |
| Emergency Room Visit | Copayment for Emergency Care $125 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $325 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $325 Prior authorization required for air/water ambulance. Air Ambulance: Copayment for Air Ambulance Services $325 Prior Authorization Required for Air Ambulance Prior authorization required for air/water ambulance. Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $325 Copayment for Medicare Covered Ambulance Services - Air $325 Prior authorization required for air/water ambulance. |
Health Care Services and Medical Supplies
Freedom Nation Prestige (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 Copayment for Routine Care $15
Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 50% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to LifeScan and Roche. Continuous glucose monitors, sensors and transmitters dispensed via retail or mail order pharmacy are limited to Abbott and Dexcom. All other desired brands will need to be obtained via an exception process or from a Durable Medical Equipment (DME) supplier. Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50% Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to LifeScan and Roche. Continuous glucose monitors, sensors and transmitters dispensed via retail or mail order pharmacy are limited to Abbott and Dexcom. All other desired brands will need to be obtained via an exception process or from a Durable Medical Equipment (DME) supplier. |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment 0% coinsurance for compression stockings, 20% for all other DME items Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% 0% coinsurance for compression stockings, 20% for all other DME items |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $50 Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $200 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $50 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50% Copayment for Medicare Covered Lab Services $0 Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Coinsurance for Medicare Covered Outpatient X-Ray Services 50% |
| 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 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $305 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 50% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $350 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per day $350 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $250 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 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Over-the-counter (OTC) Items | In-Network and Out-of-Network: Over-The-Counter (OTC) Items:
|
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $10 Copayment for Routine Foot Care $10
Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 50% Non-Medicare Covered Podiatry Services: Coinsurance for Non-Medicare Covered Podiatry Services 50% |
| 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 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 Dental: Copayment for Office Visit $10 Non-Medicare Covered Preventive Dental:
Non-Medicare Covered Comprehensive Dental: Coinsurance for Restorative services 50%
Out-of-Network: Medicare Covered Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 50% Non-Medicare Covered Preventive Dental: Non-Medicare Covered Comprehensive Dental: |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $10 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $200 every year We are offering a supplemental benefit to members which provides a $200 vision allowance to use towards glasses/frames/lenses/contacts. Out-of-Network: Eye Exams: Coinsurance for Medicare Covered Eye Exams 50% Coinsurance for Routine Eye Exams: 20% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $10 Copayment for Routine Hearing Exams $25
Hearing Aids: Copayment for Hearing Aids $699 to $999
Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 50% |
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: Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% |
