Provider
Network |
|
|
Premium
and Other Important Information2 |
Freedom
Blue Plan I
$0 monthly
plan premium
In and Out-of-Network
$1125 yearly deductible.
$3000 out-of-pocket
limit. |
Freedom
Blue Plan II
$50
monthly plan premium
In and Out-of-Network
$600 yearly
deductible.
$3000 out-of-pocket
limit. |
Doctor
and Hospital Choice |
In-Network
No referral required for network doctors,
specialists, and hospitals.
You may have to pay a separate copay for
certain doctor office visits.
Out-of-Network
You will pay less if you get prior authorization
or let the plan know before you get an
out-of-network benefit. |
In-Network
No referral required for network doctors,
specialists, and hospitals.
You may have to pay a separate copay for
certain doctor office visits.
Out-of-Network
You will pay less if you get prior authorization
or let the plan know before you get an out-of-network
benefit. |
|
Inpatient
Hospital Care |
In-Network
10 % of the cost for each Medicare-covered
hospital stay $0 copay for additional
hospital days No limit to the number of
days covered by the plan each benefit period.
Except in an emergency, your doctor must
tell the plan that you are going to be admitted
to the hospital. Out-of-Network
10 % of the cost for each hospital
stay. |
In-Network
10 % of the cost for each Medicare-covered
hospital stay $0 copay for additional
hospital days No limit to the number of
days covered by the plan each benefit period.
Except in an emergency, your doctor must
tell the plan that you are going to be admitted
to the hospital. Out-of-Network
10 % of the cost for each hospital
stay. |
|
Doctor
Office Visits |
In-Network $10 copay
for each primary care doctor visit for Medicare-covered
benefits. $10 copay for each specialist
visit for Medicare-covered benefits.
Out-of-Network 15 %
for each primary care doctor visit. 15
% for each specialist visit. |
In-Network $10 copay
for each primary care doctor visit for Medicare-covered
benefits. $10 copay for each specialist
visit for Medicare-covered benefits.
Out-of-Network 15 %
for each primary care doctor visit. 15
% for each specialist visit. |
Outpatient
Services/Surgery |
General
Authorization rules may apply.
In-Network $100 copay
for each Medicare-covered ambulatory surgical
center visit. 10 % of the cost for
each Medicare-covered outpatient hospital
facility visit. Out-of-Network
20 % of the cost for ambulatory surgical
center benefits. 10 % of the cost
for outpatient hospital facility benefits. |
General
Authorization rules may apply.
In-Network $100 copay
for each Medicare-covered ambulatory surgical
center visit. 10 % of the cost for
each Medicare-covered outpatient hospital
facility visit. Out-of-Network
20 % of the cost for ambulatory surgical
center benefits. 10 % of the cost
for outpatient hospital facility benefits. |
Ambulance
Services |
In-Network
$125 copay for Medicare-covered ambulance
benefits. Out-of-Network
$125 copay for ambulance benefits. |
In-Network
$125 copay for Medicare-covered ambulance
benefits. Out-of-Network
$125 copay for ambulance benefits. |
|
Durable
Medical Equipment |
In-Network
10 % of the cost for Medicare-covered
items. Out-of-Network
15 % of the cost for durable medical
equipment. |
In-Network
10 % of the cost for Medicare-covered
items. Out-of-Network
15 % of the cost for durable medical
equipment. |
Diagnostic
Tests, X-Rays, and Lab Services |
General
Authorization rules may apply.
In-Network 10 % of
the cost for Medicare-covered lab services.
10 % of the cost for for Medicare-covered
diagnostic procedures and tests. 10 %
of the cost for Medicare-covered X-rays.
10 % of the cost for Medicare-covered
diagnostic radiology services. 10 %
of the cost for Medicare-covered therapeutic
radiology services. Out-of-Network
15 % of the cost for diagnostic procedures,
tests, and lab services. 15 % of
the cost for therapeutic radiology services
15 % of the cost for diagnostic radiology
services |
General
Authorization rules may apply.
In-Network 10 % of
the cost for Medicare-covered lab services.
10 % of the cost for for Medicare-covered
diagnostic procedures and tests. 10 %
of the cost for Medicare-covered X-rays.
10 % of the cost for Medicare-covered
diagnostic radiology services. 10 %
of the cost for Medicare-covered therapeutic
radiology services. Out-of-Network
15 % of the cost for diagnostic procedures,
tests, and lab services. 15 % of
the cost for therapeutic radiology services
15 % of the cost for diagnostic radiology
services |
|
Prescription
Drugs |
Drugs
Covered under Medicare Part B
General 10 % of the cost
for Part B-covered drugs (not including
Part B-covered chemotherapy drugs).
10 % of the cost for Part B-covered
chemotherapy drugs. Drugs Covered
under Medicare Part D General
This plan uses a formulary. The plan will
send you the formulary. You can also see
the formulary at www.bluecrossca.com on
the web. Different out-of-pocket costs may
apply for people who
- have limited incomes,
- live in long term care facilities,
or
- have access to Indian/Tribal/Urban
(Indian Health Service).
The plan offers national in-network prescription
coverage. This means that you will pay the
same amount for your prescription drugs
if you get them at an in-network pharmacy
outside of the plan's service area (for
instance when you travel). Total yearly
drug costs are the total drug costs paid
by both you and the plan. Some drugs have
quantity limits. Your provider must get
prior authorization from Freedom Blue Plan
I for certain drugs. If the actual cost
of a drug is less than the normal copay
amount for that drug, you will pay the actual
cost, not the higher copay amount.
In-Network $0 deductible.
Some covered drugs don't count toward your
out-of-pocket drug costs. Initial
Coverage
You pay the following until total yearly
drug costs reach $2510:
Retail Pharmacy
Generics Preferred Brand Non-Preferred Brand
Non-Specialty Injectables Specialty
- $8 copay for a one-month (30-day)
supply of drugs
- $30 copay for a one-month (30-day)
supply of drugs
- $64 copay for a one-month (30-day)
supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
- $24 copay for a three-month
(90-day) supply of drugs
- $90 copay for a three-month
(90-day) supply of drugs
- $192 copay for a three-month
(90-day) supply of drugs
- 33 % coinsurance for a three-month
(90-day) supply of drugs
Long Term Care Pharmacy
Generics Preferred Brand Non-Preferred
Brand Non-Specialty Injectables Specialty
- $8 copay for a one-month (34-day)
supply of drugs
- $30 copay for a one-month (34-day)
supply of drugs
- $64 copay for a one-month (34-day)
supply of drugs
- 33 % coinsurance for a one-month
(34-day) supply of drugs
- 33 % coinsurance for a one-month
(34-day) supply of drugs
Mail Order
Generics Preferred Brand Non-Preferred
Brand Non-Specialty Injectables Specialty
- 33 % coinsurance for a one-month
(30-day) supply of drugs from a preferred
mail order pharmacy.
- $12 copay for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- $75 copay for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- $160 copay for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- 33 % coinsurance for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- 33 % coinsurance for a one-month
(30-day) supply of drugs from a non-preferred
mail order pharmacy.
- $24 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
- $90 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
- $192 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
- 33 % coinsurance for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
Coverage Gap
You pay the following: The plan covers
Only Select Generics through the gap.
Retail Pharmacy
Generics
- $8 copay for a one-month (30-day)
supply of drugs
- $24 copay for a three-month
(90-day) supply of drugs
Long Term Care Pharmacy
Generics
- $8 copay for a one-month (34-day)
supply of drugs
Mail Order
Generics
- $12 copay for a three-month
(90-day) supply of drugs from a preferred
mail order
- $24 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order
For all other covered drugs, after
your total yearly drug costs reach
$2510, you pay 100 %
until your yearly out-of-pocket drug
costs reach $4050.
Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4050, you pay
the greater of:
- $ 2.25 copay for generic
(including brand drugs treated
as generic) and $ 5.60
copay for all other drugs, or
- 5 % coinsurance.
Out-of-Network
Plan drugs may be covered in special
circumstances, for instance, illness
while traveling outside of the plan's
service area where there is no network
pharmacy. You may pay more than the
copay if you get your drugs at an
out-of-network pharmacy.
Out-of-Network Initial Coverage
You pay the following until total
yearly drug costs reach $2510:

Out-of-Network Pharmacy
Generics Preferred Brand Non-Preferred
Brand Non-Specialty Injectables Specialty
- $8 copay for a one-month (30-day)
supply of drugs
- $30 copay for a one-month (30-day)
supply of drugs
- $64 copay for a one-month (30-day)
supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
Out-of-Network Coverage Gap
You pay the following: Generics
- $8 copay for a one-month (30-day)
supply of drugs
Out-of-Network Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4050, you pay the
greater of:
- $ 2.25 copay for generic
(including brand drugs treated as
generic) and $ 5.60 copay
for all other drugs, or
- 5 % coinsurance.
|
Drugs
Covered under Medicare Part B
General 10 % of the cost
for Part B-covered drugs (not including
Part B-covered chemotherapy drugs).
10 % of the cost for Part B-covered
chemotherapy drugs. Drugs Covered
under Medicare Part D General
This plan uses a formulary. The plan will
send you the formulary. You can also see
the formulary at www.bluecrossca.com on
the web. Different out-of-pocket costs may
apply for people who
- have limited incomes,
- live in long term care facilities,
or
- have access to Indian/Tribal/Urban
(Indian Health Service).
The plan offers national in-network prescription
coverage. This means that you will pay the
same amount for your prescription drugs
if you get them at an in-network pharmacy
outside of the plan's service area (for
instance when you travel). Total yearly
drug costs are the total drug costs paid
by both you and the plan. Some drugs have
quantity limits. Your provider must get
prior authorization from Freedom Blue Plan
II for certain drugs. If the actual cost
of a drug is less than the normal copay
amount for that drug, you will pay the actual
cost, not the higher copay amount.
In-Network $0 deductible.
Some covered drugs don't count toward your
out-of-pocket drug costs. Initial
Coverage
You pay the following until total yearly
drug costs reach $2510:
Retail Pharmacy
Generics Preferred Brand Non-Preferred Brand
Non-Specialty Injectables Specialty
- $8 copay for a one-month (30-day)
supply of drugs
- $30 copay for a one-month (30-day)
supply of drugs
- $64 copay for a one-month (30-day)
supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
- $24 copay for a three-month
(90-day) supply of drugs
- $90 copay for a three-month
(90-day) supply of drugs
- $192 copay for a three-month
(90-day) supply of drugs
- 33 % coinsurance for a three-month
(90-day) supply of drugs
Long Term Care Pharmacy
Generics Preferred Brand Non-Preferred
Brand Non-Specialty Injectables Specialty
- $8 copay for a one-month (34-day)
supply of drugs
- $30 copay for a one-month (34-day)
supply of drugs
- $64 copay for a one-month (34-day)
supply of drugs
- 33 % coinsurance for a one-month
(34-day) supply of drugs
- 33 % coinsurance for a one-month
(34-day) supply of drugs
Mail Order
Generics Preferred Brand Non-Preferred
Brand Non-Specialty Injectables Specialty
- 33 % coinsurance for a one-month
(30-day) supply of drugs from a preferred
mail order pharmacy.
- $12 copay for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- $75 copay for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- $160 copay for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- 33 % coinsurance for a three-month
(90-day) supply of drugs from a preferred
mail order pharmacy.
- 33 % coinsurance for a one-month
(30-day) supply of drugs from a non-preferred
mail order pharmacy.
- $24 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
- $90 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
- $192 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
- 33 % coinsurance for a three-month
(90-day) supply of drugs from a non-preferred
mail order pharmacy.
Coverage Gap
You pay the following: The plan covers
Only Select Generics through the gap.
Retail Pharmacy
Generics
- $8 copay for a one-month (30-day)
supply of drugs
- $24 copay for a three-month
(90-day) supply of drugs
Long Term Care Pharmacy
Generics
- $8 copay for a one-month (34-day)
supply of drugs
Mail Order
Generics
- $12 copay for a three-month
(90-day) supply of drugs from a preferred
mail order
- $24 copay for a three-month
(90-day) supply of drugs from a non-preferred
mail order
For all other covered drugs, after
your total yearly drug costs reach
$2510, you pay 100 %
until your yearly out-of-pocket drug
costs reach $4050.
Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4050, you pay
the greater of:
- $ 2.25 copay for generic
(including brand drugs treated
as generic) and $ 5.60
copay for all other drugs, or
- 5 % coinsurance.
Out-of-Network
Plan drugs may be covered in special
circumstances, for instance, illness
while traveling outside of the plan's
service area where there is no network
pharmacy. You may pay more than the
copay if you get your drugs at an
out-of-network pharmacy.
Out-of-Network Initial Coverage
You pay the following until total
yearly drug costs reach $2510:
Out-of-Network Pharmacy
Generics Preferred Brand Non-Preferred
Brand Non-Specialty Injectables Specialty
- $8 copay for a one-month (30-day)
supply of drugs
- $30 copay for a one-month (30-day)
supply of drugs
- $64 copay for a one-month (30-day)
supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
- 33 % coinsurance for a one-month
(30-day) supply of drugs
Out-of-Network Coverage Gap
You pay the following: Generics
- $8 copay for a one-month (30-day)
supply of drugs
Out-of-Network Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4050, you pay the
greater of:
- $ 2.25 copay for generic
(including brand drugs treated as
generic) and $ 5.60 copay
for all other drugs, or
- 5 % coinsurance.
|
Dental
Services |
In-Network
$0 copay for Medicare-covered dental
benefits
In general, preventive dental benefits (such
as cleaning) not covered. |
In-Network
$0 copay for Medicare-covered dental
benefits
In general, preventive dental benefits (such
as cleaning) not covered. |