Blue Medicare Freedom+ (PPO) – H3404-004-0
This page outlines coverage, cost, and availability for Blue Cross and Blue Shield of North Carolina’s H3404-004-0 Medicare Advantage plan for 2025.
Health Plan Costs
💰 Monthly Premium, Deductible, Max Out-of-Pocket & Giveback
Monthly Premium: The total monthly premium is $0.00, including drug coverage. You must also pay your standard Medicare Part B premium.
Health Plan Deductible: Some health plans have a deductible (amount you pay before cost-sharing begins). This plan's deductible is $0.00.
Maximum Out-of-Pocket: All Medicare Advantage plans have an annual maximum out-of-pocket (MOOP) limit. This is the most you will pay for standard health services in a year before that plan begins paying all costs. This plan's MOOP is $9,350.00 for in-network services, excluding the cost of your Part D medications.
Part B Giveback: This plan offers a Part B premium giveback of $0.00.
Health Plan Out-of-Pocket Costs
🩺 Doctor’s Office Visits
- Primary: 20% Coinsurance
- Specialist: 20% Coinsurance
- NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
- Emergency room care: $100 Copay
- Urgent care: $45 Copay
- Ground ambulance: 20% Coinsurance
- Inpatient hospital care: $2,185.00 per stay
- Skilled Nursing Facility: $0.00 per day for days 1 through 20
$214.00 per day for days 21 through 60
$0.00 per day for days 61 and beyond
🦶 Foot Care
- Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
- Routine Foot Care: Not Covered
💆 Chiropractic Care
- Medicare-covered chiropractic: $15 Copay
- Routine chiropractic: Not Covered
🧠 Mental Health Services
- Outpatient individual therapy: 20% Coinsurance
- Outpatient group therapy: 20% Coinsurance
- Inpatient psychiatric hospital care: $2,036.00 per stay
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $30 Copay
- Occupational therapy: $30 Copay
🧰 Medical Equipment and Supplies
- Diabetes supplies: 20% Coinsurance
Prior Authorization Required - Durable medical equipment: 20% Coinsurance
Prior Authorization Required - Prosthetics: 20% Coinsurance
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: 20% Coinsurance
Prior Authorization Required - Lab services: 20% Coinsurance
Prior Authorization Required - Outpatient x-rays: 20% Coinsurance
Prior Authorization Required - Diagnostic tests and procedures: 20% Coinsurance
Prior Authorization Required
💉 Medicare Part B Drugs
- Chemotherapy: 20% Coinsurance
- Other Part B drugs (Medicare-covered): 20% Coinsurance
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: 20% Coinsurance
Prior Authorization Required - Oral exam: Not Covered
- Dental x-rays: Not Covered
- Cleaning: Not Covered
- Periodontics: Not Covered
- Endodontics: Not Covered
- Restorative Services: Not Covered
👂 Hearing Aids and Services
- Fitting/evaluation: Not Covered
- Hearing aids: Not Covered
- Hearing exam: Not Covered
👓 Vision Services
- Medicare-covered eye exam: 20% Coinsurance
- Routine eye exam: Not Covered
- Eyewear benefits: None
Prescription Drug Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) and drug plans (Part D) in several major categories using a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join Blue Medicare Freedom+ .
Plan Availability
Blue Medicare Freedom+ (H3404-004-0) is available in the following locations (click to open):
Need Help Enrolling?
Call 1-855-728-0510 (TTY 711) to speak with a licensed insurance agent and learn more about this plan and others on this site.
Or enroll online through our trusted and secure platform:
🚀 Enroll Online NowClicking this button will open MedicareEnrollment.com (powered by HealthCompare Insurance Services) and the official Blue Cross and Blue Shield of North Carolina plan page.
📄 View Plan Contact Information
| Website: | Blue Cross and Blue Shield of North Carolina Plan Page (opens in new tab) |
|---|---|
| Providers: | Blue Cross and Blue Shield of North Carolina Providers Page (opens in new tab) |
| New Member Health Plan Help: | (866)760-0823 |
| New Member TTY: | 711 |
🔍 Why This Information Matters
Many Medicare websites only show you their own phone numbers and redirect you to their sales team. We believe you deserve full access to your plan resources — including direct links to the official Blue Cross and Blue Shield of North Carolina site, provider directories, and support contacts.
That’s why we include this information here, clearly and transparently — so you can research and enroll with confidence.
🛡️ Official Medicare Enrollment Resources
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Frequently Asked Questions
📘 What does Medicare plan code H3404 004 mean?
The Medicare plan code H3404 004 identifies a specific Medicare Advantage plan. In this case, it refers to Blue Medicare Freedom+ , a PPO plan offered by Blue Cross and Blue Shield of North Carolina.
- Plan Name: Blue Medicare Freedom+
- Plan Type: PPO
- Premium: $0.00/mo + your monthly Part B premium
- Out-of-Pocket Max: $9,350.00 (in-network)
- Drug Coverage: Does not include Medicare Part D prescription drug coverage.
- CMS Star Rating: 4.5 out of 5
- Contract Year: 2025
This information is based on official CMS data and is provided for educational purposes. Always review your plan’s official documents or contact the provider directly before making enrollment decisions.
📋 What type of plan is H3404 004?
This plan is a PPO — specifically, it's an PPO plan with a Medicare Advantage contract that's offered by Blue Cross and Blue Shield of North Carolina. It comes with defined provider network rules you should be aware of.
- Plan Marketing Name: Blue Medicare Freedom+
- Network Type: Preferred Provider Organization with in- and out-of-network coverage
- Referral Requirement: Referrals are generally not required, though some services may be exceptions. Refer to the plan’s coverage tables above.
- Prescription Coverage: Does not include Medicare Part D prescription drug coverage.
Plan types like HMOs and PPOs determine whether you can go out-of-network or need referrals to see specialists.
📦 What benefits are included in H3404 004?
This plan covers all Medicare Part A and Part B services. Depending on the plan, it may also include valuable extras like dental, vision, and hearing benefits.
- Medical Services: Hospital, doctor visits, preventive care
- Prescription Drugs: Not Included
- Dental: No — this plan does not include dental benefits.
- Vision: No — this plan does not include vision benefits.
- Hearing: No — this plan does not include hearing benefits.
Benefit availability may vary by location and plan version. Confirm specific details in your plan's Evidence of Coverage (EOC).