Freedom Blue PPO Distinct (PPO) Plan Details for Calhoun County, WV
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*CMS rated this Highmark Blue Cross Blue Shield plan (H5106-029-1) 4.5 (Good+) out of 5 stars.
Freedom Blue PPO Distinct (PPO) is a Medicare Advantage plan with prescription benefits. Eligibility and enrollment periods apply. Online enrollment available.
See more Medicare Advantage Plans in Calhoun County, West Virginia.
Freedom Blue PPO Distinct Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H5106-029-1 |
| Plan Type: | PPO |
| Plan Year: | 2025 |
| Premium: | $14.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 5,700.00 /yr (in-network) |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Calhoun County, WV |
| Insured By: | Highmark Blue Cross Blue Shield |
| Summary of Benefits |
|---|
Highmark Blue Cross Blue Shield Out-of-Pocket Costs
This Highmark Blue Cross Blue Shield Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H5106-029-1.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $20 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $35 Copay |
| Ground ambulance: | $270 Copay |
| Inpatient hospital care: | $375.00 per stay |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $20 Copay |
| Routine Foot Care: | $20 Copay |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $15 Copay Prior Authorization Required |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $40 Copay |
| Outpatient group therapy: | $40 Copay |
| Inpatient psychiatric hospital care: | $425.00 per day for days 1 through 3 $0.00 per day for days 4 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $25 Copay Prior Authorization Required |
| Occupational therapy: | $25 Copay Prior Authorization Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $200 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | $15 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | Not Covered |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $20 Copay |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $2,500.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Not Covered |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam | $ to $20 Copay |
| Routine eye exam | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our Freedom Blue PPO Distinct Summary of Benefits information.
Prescription Drug Costs & Benefits
Freedom Blue PPO Distinct includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Part D Prescription Drug Premium
The table below outlines the Part D premium costs for this Highmark Blue Cross Blue Shield plan, showing the monthly portion of the total premium dedicated to prescription drug coverage. While the Part D premium is included in the overall plan cost, some plans may have supplemental charges or offer assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security initiative that helps individuals with limited income and resources reduce or eliminate Part D expenses.
| Basic Part D Premium: | $11.10 |
| Supplemental Part D Premium: | $2.90 |
| Total Part D Premium: | $14.00 |
| Low Income Premium Subsidy: | $48.36 |
| Low Income Premium Subsidy CMS Pays: | $11.10 |
| Low Income Subsidy Premium: | $2.90 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. You must pay this amount at the pharmacy before Highmark Blue Cross Blue Shield begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Freedom Blue PPO Distinct has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Preferred Generic | $0.00 | $0.00 | |
| Generic | $0.00 | $0.00 | |
| Preferred Brand | 25.00% | 0.00% | |
| Non-Preferred Drug | 50.00% | 0.00% | |
| Specialty Tier | 33.00% | 33.00% | |
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for Freedom Blue PPO Distinct .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- Freedom Blue PPO Prestige (PPO)
- Freedom Blue PPO Signature (PPO)
- Freedom Blue PPO Merit (PPO)
- Freedom Blue PPO Valor (PPO)
- Freedom Blue PPO Standard (PPO)
- Freedom Blue PPO Signature (PPO)
- Freedom Blue PPO Merit (PPO)
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Highmark Blue Cross Blue Shield
| Website: | Highmark Blue Cross Blue Shield Plan Page |
|---|---|
| Providers: | Highmark Blue Cross Blue Shield Providers Page |
| Formulary: | Highmark Blue Cross Blue Shield Formulary Page |
| Pharmacy: | Highmark Blue Cross Blue Shield Pharmacy Page |
| New Member Health Plan Help: | (866)739-1899 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (866)739-1899 |
| New Member Part D TTY Users: | 711 |
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.
Citations & References
- Highmark Blue Cross Blue Shield, http://medicare.highmark.com, Last Accessed February 20, 2024
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.