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Silver Freedom
2023 Benefits Summary
This is a summary of what our plan covers and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the Evidence of Coverage, this legal member contract is the primary source of the coverage information and supersedes all other information.
Download the Summary of Benefits
| Covered Services | What You Pay |
| Physician Services / Doctor Office Visits | PCP - $0 Specialist - $20 |
| Annual Wellness Visit | $0 |
| Telehealth Benefit | PCP - $0 Specialist - $15 |
| Preventive Health Screenings | $0 |
| Inpatient Hospital Care | $325 per stay |
| Outpatient Diagnostic Tests and Therapeutic Services & Supplies | Diagnostic labs & x-rays $0 Advanced Radiology - $150 |
| Emergency Care | $120 |
| Ambulance Services | $200 |
| Urgently Needed Services | $25 |
| Convenient Care | $25 CVS Minute Clinics only |
| Over-the-Counter Items (OTC) | $50 every quarter |
| Outpatient Hospital Observation | $250 |
| Outpatient Surgery | ASC - $225 Hospital $250 |
| Outpatient Rehab Services | PT and OT - $10 Speech - $20 |
| Outpatient Mental Health Care | Individual or Group - $20 |
| Outpatient Substance Abuse Services | Individual or Group - $20 |
| Durable Medical Equipment (DME) and Related Supplies | 15-20% coinsurance |
| Prosthetic Devices and Related Supplies | 20% coinsurance |
| Medicare Part B Prescription Drugs | 20% coinsurance (including chemotherapy) |
| Services to Treat Kidney Disease | 20% coinsurance |
| Pulmonary Rehabilitation Services | $20 |
| Cardiac Rehabilitation Services | $20 |
| Chiropractic Services | $20 |
| Acupuncture | $20 |
| Podiatry Services | $20 |
| Home Health Agency Care | $10 |
| Inpatient Mental Health Care | $325 per stay |
| Medical Nutrition Therapy | $0 |
| Dental Services (Medical Only) | $20 |
| Preventative Dental | $1,500 combined annual max for Preventative and Comprehensive Dental |
| Comprehensive Dental | $1,500 combined annual max for Preventative and Comprehensive Dental |
| Diabetes Self Management Training, Diabetic Services and Supplies | 0% - 20% coinsurance |
| Immunizations | $0 |
| Transportation | You pay nothing. 20 one-way trips to approved medical appointments. |
| Smoking Cessation | $0 |
| Hearing Services | $0 - $20 for exams and $750 per ear towards the cost of hearing aid(s) every 3 years |
| Vision Care | $0 - $20 and $125 plan allowance per year |
| Healthy Living Rewards | Included |
| COVID-19 Benefit | Acute inpatient hospital copay waived with COVID-19 diagnosis. Post hospital discharge meal delivery included. |
Plan Premium
The monthly fee you pay the plan for your health care. The amount shown does not include the Part B premium you already pay to the government.
| Plan | Monthly Premium |
| Silver Freedom | $0 |
Plan Summaries
- Medical Coverage
- Comprehensive Dental
- Over-the-Counter Allowance
- COVID-19 Coverage
- Wellness Benefit Allowance
- Hearing & Vision Allowances
- No Referrals for Out-of-Network Services
- And more
You Must:
- Be eligible for Medicare Part A and enrolled in Part B,
- Continue to pay Part B premiums,
- Live in the plan service area, and
How Much Does it Cost
The monthly plan premium to enroll in the Silver Freedom plan is $0. Additionally, you must maintain your Medicare Part B coverage to be a member of any Medicare Advantage plan. Most people will pay the standard Part B premium amount. Please call Social Security at 1-800-772-1213 for information about your Part B premium.