Blue Medicare Freedom+ (PPO) Medicare Advantage Plan H3404-004 • 2027 • Surry County, NC
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $9850.00In-network
- Part B Giveback
- −$76.00 reduction
- Prescription Coverage
- Not Included
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- Surry County, NC
- Local Enrollment
- 0 beneficiaries in Surry County
Blue Medicare Freedom+ (PPO) Introduction
This Medicare Advantage PPO plan, Blue Medicare Freedom+, is offered by Blue Cross and Blue Shield of North Carolina and uses a Preferred Provider Organization (PPO) provider network. It comes without prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $9850.00. The plan is identified by CMS Plan ID H3404-004.
Enrollment in this plan requires residence in Surry County, North Carolina. CMS enrollment data reports 0 plan members in Surry County. New members can call the plan directly at (866)760-0823 (TTY 711) for assistance.
Compare Similar Plans in Surry County
Compare this plan with the two most-enrolled PPO plans available in Surry County, North Carolina. Enrollment is based on CMS local enrollment data.
| Plan Detail | Blue Medicare Freedom+ | Blue Medicare PPO Enhanced | AARP Medicare Advantage from UHC NC-0016 |
|---|---|---|---|
| CMS Plan ID | H3404-004-0 |
H3404-003-2 |
H2406-034-0 |
| Local Enrollment | 0 | 795 | 707 |
| Monthly Premium | $0.00 | $70.00 | $53.00 |
| Medical Deductible | $0.00 | $170 | $1,000 |
| Maximum Out-of-Pocket | $9,850.00 | $6,900.00 | $4,450.00 |
| Part B Giveback | −$76.00 reduction | Not offered | Not offered |
| Primary Care | 20% coinsurance | $0 copay | $0 copay |
| Specialist | 20% coinsurance | $30 copay | $0-$45 copay |
| Part D Deductible | Not Applicable | $700.00 | $595.00 |
| CMS Star Rating | 4.5 | 4.5 | 4.0 |
| Dental | Not covered | $0 copay | $0 copay |
| Vision | Not covered | $0 copay | $0 copay |
| Hearing | Not covered | Not covered | $0 copay |
Want to explore more options? Browse all Medicare Advantage plans in Surry County, or compare Medicare Advantage plans across North Carolina, including premiums, out-of-pocket costs, CMS ratings, and enrollment.
Plan Benefits
Blue Medicare Freedom+ includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H3404-004.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H3404-004-0 Cost Compare.
Office Visits
- Primary care
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Specialist
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance
Preventive and Wellness Services
- Annual wellness exam
- In-network: $0 copay
Out-of-network: $0 copay - Telehealth benefit
- In-network: 0%-20% coinsurance
- Routine chiropractic
- Not covered
- Fitness benefits
- Coming soon
- Health education
- Not covered
- Counseling services
- Not covered
- Over-the-counter drug benefits
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Lab services
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Outpatient x-rays
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Diagnostic tests and procedures
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance
Emergency and Urgent Care Services
- Emergency room care
- $115 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $40 copay
- Inpatient hospital care
- In-network:
Tier 1
$868 Lifetime Reserve Days for days 1-60
$2,241 per stay
Out-of-network:
40% per stay - Skilled Nursing Facility
- In-network:
Tier 1
$0 per day for days 1-20
$221 per day for days 21-60
$221 per day for days 61-100
Out-of-network:
40% per stay - Ground ambulance
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance
Mental Health Services
- Outpatient individual therapy
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Outpatient group therapy
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Inpatient psychiatric hospital care
- In-network:
Tier 1
$868 Lifetime Reserve Days for days 1-60
$2,241 per stay
Out-of-network:
40% per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $35 copay
Out-of-network: 40% coinsurance - Occupational therapy
- In-network: $35 copay
Out-of-network: 40% coinsurance
Medical Equipment and Supplies
- Diabetes supplies
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Durable medical equipment
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance - Prosthetics
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
Out-of-network: 40% coinsurance - Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Out-of-network: 40% coinsurance
Dental Services
- Oral exam
- Not covered
- Dental x-rays
- Not covered
- Cleaning
- Not covered
- Periodontics
- Not covered
- Endodontics
- Not covered
- Restorative services
- Not covered
- Implant services
- Not covered
- Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- Not covered
Vision Services
- Routine eye exam
- Not covered
- Contact lenses
- Not covered
- Eyeglass frames only
- Not covered
- Eyeglass lenses only
- Not covered
- Eyeglasses (frames & lenses)
- Not covered
- Upgrades
- Not covered
Hearing Services
- Hearing exam
- Not covered
- Fitting/evaluation
- Not covered
- Prescription hearing aids
- Not covered
- OTC hearing aids
- Not covered
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- Not covered
- Wigs for chemotherapy-related hair loss
- Coming soon
- Alternative therapies
- Not covered
- Massage therapy
- Not covered
- Home/bathroom safety devices
- Not covered
Certain preventive services are covered 100% by Blue Medicare Freedom+ as a Part B benefit.
Prescription Drug Coverage
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Performance Ratings (Contract ID: H3404)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 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 |
Contact Information for Blue Cross and Blue Shield of North Carolina
- Website
- Blue Cross and Blue Shield of North Carolina Plan Page
- Providers
- Blue Cross and Blue Shield of North Carolina Providers Page
- Formulary
- Blue Cross and Blue Shield of North Carolina Formulary Page
- Pharmacy
- Blue Cross and Blue Shield of North Carolina Pharmacy Page
- New Member Health Plan Help
- (866)760-0823
- New Member Health Plan TTY
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Blue Cross and Blue Shield of North Carolina (official source) | https://www.bluecrossnc.com/medicare | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
MedicarePlans.com is an independent informational resource and is not affiliated with or endorsed by the U.S. Government or the federal Medicare program.
Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.