4

4 out of 5 stars* for plan year 2024

Plan ID: H3916-015

What You Need to Know:

  • Freedom Blue PPO Standard (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 $175, 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 $5,000 per year (in-network).
  • Freedom Blue PPO Standard (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 $48.

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

$175

Monthly Premium

Medicare Plan Features
Monthly Premium: $175.00
Part C Premium: $90.40
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$175.00 $90.40 $47.90 $36.70 $84.60 $0 0.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H3916-018
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $5,000
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Luzerne, Pennsylvania: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
254 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 Luzerne, Pennsylvania: 2,826 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
$90.40 $47.90 $36.70 $175.00
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
$137.50 $75.20 $165.60 $65.90 $156.30 $56.50 $146.90
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%

Other Medicare Advantage Plans in Luzerne, Pennsylvania

Plan Name Type Premium MOOP Rx Deduct. Rating
Vibra Health Plan Enhanced Complete (PPO) (2023)Local PPO$5,800$0
3
Vibra Essential Advocate (PPO) (2023)Local PPO$6,700$0
3
Aetna Medicare Value (PPO) (2023)Local PPO$7,550$0
5
Humana Gold Plus H6622-036 (HMO) (2023)Local HMO$6,700$0
4
HumanaChoice H5525-007 (PPO) (2023)Local PPO$6,700$0
4
HumanaChoice H5525-038 (PPO) (2023)Local PPO$6,700$0
4
Aetna Medicare Advantra Silver (PPO) (2023)Local PPO$7,550$0
5
HumanaChoice R0923-001 (Regional PPO) (2023)Regional PPO *$4,900$-
3
Humana Gold Choice H8145-052 (PFFS) (2023)PFFS$-$360
4
HumanaChoice R0923-002 (Regional PPO) (2023)Regional PPO$6,700$0
3
HumanaChoice H5216-120 (PPO) (2023)Local PPO$6,700$0
4
Humana Gold Choice H8145-055 (PFFS) (2023)PFFS *$-$-
4
Aetna Medicare Advantra Silver Plus (PPO) (2023)Local PPO$7,550$0
5
Humana Honor (PPO) (2023)Local PPO *$6,700$-
4
Aetna Medicare Advantra Eagle (HMO) (2023)Local HMO *$4,000$-
5
Aetna Medicare Gold Plan (PPO) (2023)Local PPO$7,550$0
5
Geisinger Gold Classic Essential Rx (HMO) (2023)Local HMO$7,550$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
Geisinger Gold Classic Advantage (HMO) (2023)Local HMO *$3,450$-
4
Community Blue Medicare HMO Signature (HMO) (2023)Local HMO$6,700$0
4
Aetna Medicare Advantra Gold (HMO) (2023)Local HMO$7,550$0
5
Aetna Medicare Advantra Premier (HMO) (2023)Local HMO$7,550$0
5
Geisinger Gold Preferred Advantage Rx (PPO) (2023)Local PPO$4,000$0
3
Geisinger Gold Classic Advantage Rx (HMO) (2023)Local HMO$3,450$0
4
Community Blue Medicare PPO Distinct (PPO) (2023)Local PPO$6,500$0
4
Geisinger Gold Classic Complete Rx (HMO) (2023)Local HMO$4,900$0
4
Freedom Blue PPO Deluxe (PPO) (2023)Local PPO$4,500$0
4
Geisinger Gold Preferred Complete Rx (PPO) (2023)Local PPO$6,700$0
3
Community Blue Medicare PPO Signature (PPO) (2023)Local PPO$7,550$0
4
Lasso Healthcare Growth (MSA) (2023)MSA *$-$-
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
Freedom Blue PPO ValueRx (PPO) (2023)Local PPO$5,500$0
4
Aetna Medicare Silver (HMO) (2023)Local HMO$7,550$0
5
Lasso Healthcare Growth Plus (MSA) (2023)MSA *$-$-
4
Medicare Advantage Plans by Highmark Inc
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 Deluxe (PPO) (2023)Local PPO$4,500$0
4
Community Blue Medicare PPO Signature (PPO) (2023)Local PPO$7,550$0
4
Freedom Blue PPO Basic (PPO) (2023)Local PPO *$5,900$-
4
Freedom Blue PPO ValueRx (PPO) (2023)Local PPO$5,500$0
4

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