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Medicare Advantage · Local PPO
Highmark Blue Cross Blue Shield or Highmark Blue Shield
Plan year 2026

Freedom Blue PPO Classic (PPO) H3916-001

4.5 · 2026 Star Rating · source: CMS · Ratings are updated annually
Monthly premium
$248
+ your Part B premium
Max out-of-pocket
$4,500
in-network annual cap
Primary care
$0
per visit copay
Specialist
$25
per visit

Your costs at a glanceIn-network, for the 2026 plan year

Rx deductible
$0
Inpatient hospital
$210
per stay
no limit on covered hospital days
Inpatient mental health
$210
per stay
Outpatient surgery
$150
Emergency room
$130
Urgent care
$50

What's included, and what it's actually worth5 benefits included. Tap any card for the detail

Hearing

$500/yr hearing aid allowance ($25 exam copay)
Hearing aid allowance$500/yr hearing aid allowance
Hearing exam$25 copay
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Vision

$425/yr eyewear allowance ($25 exam copay)
Eyewear allowance$425/yr eyewear allowance
Routine eye exam$25 copay
This is a supplemental benefit with plan-specific limits. See plan documents for details.
See more details about this plan
Doctor Visits: PCP$0 copay
In-network$0 copay per visit
Doctor Visits: Specialist$25 copay
In-network$25 copay per visit
Inpatient Hospital$210 per stay
In-network$210 per stay
Benefit limitNone — additional covered days are unlimited
Outpatient Surgery$150 copay
In-network$150 copay per procedure
Mental Health$210 per stay
Inpatient psychiatric$210 per stay
DentalPreventive dental (cost sharing varies by service)
DetailsPreventive dental (cost sharing varies by service)
This is a supplemental benefit with plan-specific limits. See plan documents for details.
Transportation24 one-way trips/year
Trips per year24 one-way trips/year
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
$0
Preferred Generic
Tier 2
$13
Generic
Tier 3
$45
Preferred Brand
Tier 4
$95
Non-Pref Brand
Tier 5
33%
Specialty

Our take

Where this plan shines

This plan’s out-of-pocket maximum is below the national median.
See your primary doctor for $0.
The specialist copay ($25) is among the more affordable options.
No separate drug deductible.
Highly rated by CMS (4.5 stars).

Things to know before you enroll

Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits (PDF)
Download the plan's official Summary of Benefits document
Evidence of Coverage (PDF)
Complete plan details and rules
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (833)544-1060 (TTY: 711) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Every year, Medicare evaluates plans based on a 5-star rating system. Star ratings are based on 2026 data and may change annually.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
  2. The Pocket Protector is not connected with or endorsed by the United States government or the federal Medicare program.

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Freedom Blue PPO Classic (PPO) - Highmark Blue Cross Blue Shield or Highmark Blue Shield | The Pocket Protector