4

4 out of 5 stars* for plan year 2024

Plan ID: H3916-005

What You Need to Know:

  • Freedom Blue PPO Deluxe (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $289, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $4,500 per year (in-network).
  • Freedom Blue PPO Deluxe (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $82.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$289

Monthly Premium

Medicare Plan Features
Monthly Premium: $289.00
Part C Premium: $168.0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$289.00 $168.0 $81.60 $39.40 $121.0 $0 0.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H3916-012
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $4,500
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Lebanon, Pennsylvania: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
114 members 4.5 out of 5 Stars. 4 out of 5 Stars. 4 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 4,266 drugs
Number of Members Enrolled in this Plan in Lebanon, Pennsylvania: 4,349 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$168.00 $81.60 $39.40 $289.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$251.50 $111.60 $279.60 $102.30 $270.30 $92.90 $260.90
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
534 $0.00 1410 $13.00 600 $45.00 791 $95.00 931 33%

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Vibra Essential Advocate (PPO) (2023)Local PPO$6,700$0
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UPMC for Life PPO Rx Enhanced (PPO) (2023)Local PPO$7,550$0
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Humana Gold Plus H6622-035 (HMO) (2023)Local HMO$6,700$0
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HumanaChoice R0923-001 (Regional PPO) (2023)Regional PPO *$4,900$-
3
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Cigna True Choice Plus Medicare (PPO) (2023)Local PPO$6,150$0
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Aetna Medicare Advantra Premier Plus (PPO) (2023)Local PPO$4,900$0
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Humana Gold Choice H8145-052 (PFFS) (2023)PFFS$-$360
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HumanaChoice H5525-038 (PPO) (2023)Local PPO$6,700$0
4
Aetna Medicare Advantra Silver (PPO) (2023)Local PPO$7,550$0
5
HumanaChoice R0923-002 (Regional PPO) (2023)Regional PPO$6,700$0
3
Humana Gold Choice H8145-055 (PFFS) (2023)PFFS *$-$-
4
HumanaChoice H5216-120 (PPO) (2023)Local PPO$6,700$0
4
Aetna Medicare Advantra Silver Plus (PPO) (2023)Local PPO$7,550$0
5
Health Partners Medicare Prime (HMO-POS) (2023)Local HMO$7,550$0
4
Health Partners Medicare Complete (HMO-POS) (2023)Local HMO$7,550$0
4
Humana Honor (PPO) (2023)Local PPO *$6,700$-
4
Aetna Medicare Premier Plus (PPO) (2023)Local PPO$6,300$0
5
Aetna Medicare Gold Plan (PPO) (2023)Local PPO$7,550$0
5
BlueJourney Premier (HMO) (2023)Local HMO$3,400$0
3
BlueJourney Value (HMO) (2023)Local HMO$4,500$0
3
Geisinger Gold Classic Essential Rx (HMO) (2023)Local HMO$7,550$0
4
BlueJourney Essential (HMO) (2023)Local HMO$6,700$0
3
Cigna Preferred Medicare (HMO) (2023)Local HMO$6,900$0
4
Geisinger Gold Classic 360 Rx (HMO) (2023)Local HMO$7,550$0
4
HumanaChoice H5216-116 (PPO) (2023)Local PPO *$3,900$-
4
Community Blue Medicare HMO Signature (HMO) (2023)Local HMO$6,700$0
4
Humana Value Plus H5216-117 (PPO) (2023)Local PPO$6,700$420
4
Geisinger Gold Classic Advantage (HMO) (2023)Local HMO *$3,450$-
4
Geisinger Gold Preferred Advantage Rx (PPO) (2023)Local PPO$4,000$0
3
Aetna Medicare Advantra Premier (HMO) (2023)Local HMO$7,550$0
5
UPMC for Life HMO Rx Enhanced (HMO) (2023)Local HMO$7,550$0
4
AARP Medicare Advantage (HMO) (2023)Local HMO$6,700$130
5
Geisinger Gold Classic Advantage Rx (HMO) (2023)Local HMO$3,450$0
4
Aetna Medicare Advantra Eagle (HMO) (2023)Local HMO *$4,000$-
5
UPMC for Life HMO Rx (HMO) (2023)Local HMO$7,550$0
4
Geisinger Gold Classic Complete Rx (HMO) (2023)Local HMO$4,900$0
4
Community Blue Medicare PPO Distinct (PPO) (2023)Local PPO$6,500$0
4
AARP Medicare Advantage Patriot (HMO) (2023)Local HMO *$5,500$-
5
Allwell Medicare Boost (HMO) (2023)Local HMO$7,550$0
4
Geisinger Gold Preferred Complete Rx (PPO) (2023)Local PPO$6,700$0
3
AARP Medicare Advantage Choice Plan 1 (PPO) (2023)Local PPO$6,700$95
5
AARP Medicare Advantage Choice Plan 2 (PPO) (2023)Local PPO$5,900$150
5
UPMC for Life HMO Deductible with Rx (HMO) (2023)Local HMO$7,550$0
4
Geisinger Gold Preferred Enhanced Rx (PPO) (2023)Local PPO$6,700$0
3
Freedom Blue PPO Basic (PPO) (2023)Local PPO *$5,900$-
4
AARP Medicare Advantage Choice Plan 3 (PPO) (2023)Local PPO$6,700$0
5
Community Blue Medicare PPO Signature (PPO) (2023)Local PPO$7,550$0
4
Lasso Healthcare Growth (MSA) (2023)MSA *$-$-
4
Allwell Medicare (HMO) (2023)Local HMO$6,700$0
4
Freedom Blue PPO Standard (PPO) (2023)Local PPO$5,000$0
4
Lasso Healthcare Growth Plus (MSA) (2023)MSA *$-$-
4
BlueJourney Classic (PPO) (2023)Local PPO$6,700$0
5
Freedom Blue PPO ValueRx (PPO) (2023)Local PPO$5,500$0
4
Allwell Medicare Simple (HMO) (2023)Local HMO *$3,450$-
4
Aetna Medicare Silver (HMO) (2023)Local HMO$7,550$0
5
UPMC for Life HMO Rx Choice (HMO) (2023)Local HMO$7,550$0
4
UPMC for Life HMO No Rx (HMO) (2023)Local HMO *$7,550$-
4
BlueJourney Prime (PPO) (2023)Local PPO$4,000$0
5
BlueJourney Select (PPO) (2023)Local PPO$6,700$0
5
Allwell Medicare Complement (HMO) (2023)Local HMO$7,550$445
4
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Community Blue Medicare HMO Signature (HMO) (2023)Local HMO$6,700$0
4
Community Blue Medicare PPO Distinct (PPO) (2023)Local PPO$6,500$0
4
Freedom Blue PPO Basic (PPO) (2023)Local PPO *$5,900$-
4
Community Blue Medicare PPO Signature (PPO) (2023)Local PPO$7,550$0
4
Freedom Blue PPO Standard (PPO) (2023)Local PPO$5,000$0
4
Freedom Blue PPO ValueRx (PPO) (2023)Local PPO$5,500$0
4

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