Freedom Blue PPO Standard (PPO) Medicare Advantage Plan H5106-034-2 • 2027
- Monthly Premium
- $172.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $6500.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $700.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 1,289 beneficiaries
Freedom Blue PPO Standard (PPO) Introduction
CMS Plan ID H5106-034-2 identifies Freedom Blue PPO Standard, a Medicare Advantage PPO plan offered by Highmark Blue Cross Blue Shield. The plan uses a Preferred Provider Organization (PPO) provider network and comes with prescription drug coverage. Its costs for the 2027 plan year include a $172.00 monthly premium, $0.00 medical deductible, and $6500.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $700.00.
Plan Benefits
Freedom Blue PPO Standard has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H5106-034-2.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Specialist | In-network: $35 copay Out-of-network: $35 copay |
In-network: $35 copay Out-of-network: $35 copay |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay |
| Telehealth benefit | In-network: $0-$50 copay | In-network: $0-$50 copay |
| Routine chiropractic | In-network: $15 copay Out-of-network: $15 copay |
In-network: $15 copay Out-of-network: $15 copay |
| Fitness benefits | Coming soon | In-network: $0 copay Out-of-network: 50% coinsurance |
| Health education | Not covered | Not covered |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | Not covered | Not covered |
| Health transportation (non-emergency) | Coming soon | In-network: $0 copay Out-of-network: 30% coinsurance |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $75 copay Out-of-network: $75 copay |
In-network: $75 copay Out-of-network: $75 copay |
| Lab services | In-network: $0-$10 copay Out-of-network: $10 copay |
In-network: $0-$10 copay Out-of-network: $10 copay |
| Outpatient x-rays | In-network: $25 copay Out-of-network: $25 copay |
In-network: $25 copay Out-of-network: $25 copay |
| Diagnostic tests and procedures | In-network: $0-$10 copay Out-of-network: $10 copay |
In-network: $0-$10 copay Out-of-network: $10 copay |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $130 copay | $130 copay |
| Worldwide emergency care | Coming soon | $130 copay |
| Urgent care | $50 copay | $50 copay |
| Inpatient hospital care | In-network: Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
In-network: Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
| Skilled Nursing Facility | In-network: Tier 1 $0 per day for days 1-20 $221 per day for days 21-100 Out-of-network: 30% per stay |
In-network: Tier 1 $0 per day for days 1-20 $218 per day for days 21-100 Out-of-network: 30% per stay |
| Ground ambulance | In-network: $330 copay Out-of-network: $330 copay, 30% coinsurance |
In-network: $330 copay Out-of-network: $330 copay, 30% coinsurance |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $35 copay Out-of-network: $35 copay |
In-network: $35 copay Out-of-network: $35 copay |
| Outpatient group therapy | In-network: $35 copay Out-of-network: $35 copay |
In-network: $35 copay Out-of-network: $35 copay |
| Inpatient psychiatric hospital care | In-network: Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
In-network: Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $35 copay Out-of-network: $35 copay |
In-network: $35 copay Out-of-network: $35 copay |
| Occupational therapy | In-network: $35 copay Out-of-network: $35 copay |
In-network: $35 copay Out-of-network: $35 copay |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: 0%-20% coinsurance Out-of-network: 30% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 30% coinsurance |
| Durable medical equipment | In-network: 20% coinsurance Out-of-network: 30% coinsurance |
In-network: 20% coinsurance Out-of-network: 30% coinsurance |
| Prosthetics | In-network: 20% coinsurance Out-of-network: 30% coinsurance |
In-network: 20% coinsurance Out-of-network: 30% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance Out-of-network: 30% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 30% coinsurance |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance Out-of-network: 30% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 30% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay Out-of-network: 30% coinsurance |
In-network: $15 copay Out-of-network: 30% coinsurance |
| Dental x-rays | In-network: $0 copay Out-of-network: 30% coinsurance |
In-network: $15 copay Out-of-network: 30% coinsurance |
| Cleaning | In-network: $0 copay Out-of-network: 30% coinsurance |
In-network: $15 copay Out-of-network: 30% coinsurance |
| Periodontics | Not covered | Not covered |
| Endodontics | Not covered | Not covered |
| Restorative services | Not covered | Not covered |
| Implant services | Not covered | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | Not covered | Not covered |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: $50 copay |
In-network: $0 copay Out-of-network: $50 copay |
| Contact lenses | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only | In-network: $0-$40 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses) | In-network: $0-$40 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Upgrades | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay Out-of-network: $35 copay |
In-network: $0 copay Out-of-network: $35 copay |
| Fitting/evaluation | Not covered | Not covered |
| Prescription hearing aids | In-network: $399-$699 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $399-$699 copay Out-of-network: $0 copay, 0% coinsurance |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | Not covered | Not covered |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | Not covered | Not covered |
| Massage therapy | Not covered | Not covered |
| Home/bathroom safety devices | In-network: 20% coinsurance Out-of-network: 30% coinsurance |
In-network: 20% coinsurance Out-of-network: 30% coinsurance |
Certain preventive services are covered 100% by Freedom Blue PPO Standard as a Part B benefit.
Prescription Drug Coverage
Freedom Blue PPO Standard includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $129.20 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $129.20 |
| Low-Income Premium Subsidy: | $12.80 |
| Low-Income Premium Subsidy Paid by CMS: | $12.80 |
| Low-Income Subsidy Premium: | $116.40 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $700.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Highmark Blue Cross Blue Shield starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Freedom Blue PPO Standard may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $5.00 copay | Coming soon |
| Preferred Brand | 19% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H5106)
Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.
| 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 Highmark Blue Cross Blue Shield
- Website
- Highmark Blue Cross Blue Shield Plan Page
- Providers
- Highmark Blue Cross Blue Shield Providers Page
- Formulary
- Highmark Blue Cross Blue Shield Formulary Page
- Pharmacy
- Highmark Blue Cross Blue Shield Pharmacy Page
- New Member Health Plan Help
- (866)739-1899
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (866)739-1899
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
Freedom Blue PPO Standard (H5106-034-2) is available in the following locations:
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About Freedom Blue PPO Standard (PPO)
Is there a monthly premium for this plan in 2027?
The plan’s monthly premium is $172.00 for 2027. The Part B premium is not included.
What is the in-network MOOP for plan H5106-034-2?
For 2027, the in-network maximum out-of-pocket is $6500.00. The plan pays 100% of covered in-network services beyond this amount.
What is the CMS star rating for this plan?
CMS rates this plan at ★0.0 out of 5 stars for 2027.
What is the current enrollment for Freedom Blue PPO Standard?
The plan has 1,289 enrolled beneficiaries according to CMS.
What is the Part D deductible for plan H5106-034-2?
The Part D deductible is $700.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | CMS Version |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | CY2027 Landscape (202609.1) |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | 2027 Star Ratings Data Tables |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | PBP Benefits-2027 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | 2026-09 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Highmark Blue Cross Blue Shield (official source) | http://medicare.highmark.com | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Explore your Medicare coverage options | 25 May, 2025 |
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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.