In-network
Inpatient hospital
Days 1–7 $290 / day
Days 8–90 $0 / day
Total of listed copays · 7 charged days $2,030
Out-of-network
Tier 1: 50% coinsurance
Point of service
Not separately reported
● CMS 2027 plan record
Freedom Valor (PPO)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network$355 copay
Air · in-network$355 copay
Emergency services
Emergency room
$130 copay
Waived if admitted within 1 days
Medical maximum
Maximum out-of-pocket
In-network$6,700
Combined in + out$10,750
Skilled care at home
Home health
In-network$0 cost share
Out-of-network50% coinsurance
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + DNot reported
CMS reports a Part B premium reduction of $50 per month.
Quick view
Primary care physician
In: Primary Care Physician Services: $0 cost share · Out: 7a: 50% coinsurance
Quick view
Specialist
In: Physician Specialist Services: $35 copay · Out: 7d: 50% coinsurance
Quick view
Preventive care
In: Annual Physical Exam: $0 cost share; Kidney Disease Education Services: $0 cost share; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share · Out: 14b: 50% coinsurance; 14d: 50% coinsurance; 14e1: 50% coinsurance; 14e2: 50% coinsurance; 14e4: 50% coinsurance; 14e5: 50% coinsurance; 14a: 50% coinsurance
Quick view
Diagnostic procedures & tests
In: Diagnostic Procedures/Tests: $0–$10 copay · Out: 8a1: 50% coinsurance
Quick view
Laboratory services
In: Lab Services: $0–$10 copay · Out: 8a2: 50% coinsurance
Quick view
X-rays & standard imaging
In: Outpatient X-Ray Services: $45 copay · Out: 8b3: 50% coinsurance
Quick view
MRI, CT & PET imaging
In: Diagnostic Radiological Services: $225 copay · Out: 8b1: 50% coinsurance
Quick view
Urgent care
In: Urgently Needed Services: $40 copay · Out: Not separately reported
Quick view
Emergency room
In: $130 copay · Out: Not separately reported
Quick view
Ground ambulance
In: $355 copay · Out: $355 copay
Quick view
Air ambulance
In: $355 copay · Out: $355 copay
Quick view
Outpatient hospital
In: Outpatient Hospital Services: $0–$325 copay; Observation Services: $325 copay · Out: 9a1: 50% coinsurance; 9a2: 50% coinsurance
Quick view
Outpatient surgery / ASC
In: Ambulatory Surgical Center (ASC) Services: $0–$225 copay · Out: 9b: 50% coinsurance
Quick view
Home health
In: $0 cost share · Out: 50% coinsurance
Quick view
Skilled nursing facility
In: Skilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100 · Out: Skilled nursing facility: Tier 1: 50% coinsurance
Quick view
Cardiac & pulmonary rehabilitation
In: Cardiac Rehabilitation Services: $15 copay; Intensive Cardiac Rehabilitation Services: $15 copay; Pulmonary Rehabilitation Services: $15 copay; SET for PAD Services: $15 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: 3-1: 50% coinsurance; 3-2: 50% coinsurance; 3-3: 50% coinsurance; 3-4: 50% coinsurance
Quick view
Occupational therapy
In: Occupational Therapy Services: $15 copay · Out: 7c: 50% coinsurance
Quick view
Physical & speech therapy
In: Physical Therapy and Speech-Language Pathology Services: $15 copay · Out: 7i: 50% coinsurance
Quick view
Mental health services
In: Partial Hospitalization Program: $55 copay; Individual Sessions for Mental Health Specialty Services: $5 copay; Group Sessions for Mental Health Specialty Services: $5 copay; Individual Sessions for Psychiatric Services: $5 copay; Group Sessions for Psychiatric Services: $5 copay; Inpatient psychiatric hospital: Tier 1: $260 / day for days 1–6; $0 / day for days 7–90 · Out: 5a: 50% coinsurance; 7e1: 50% coinsurance; 7e2: 50% coinsurance; 7h1: 50% coinsurance; 7h2: 50% coinsurance; Inpatient psychiatric hospital: Tier 1: 50% coinsurance
Quick view
Substance use treatment
In: Intensive Outpatient Program Services: $55 copay; Individual Sessions for Outpatient Substance Abuse: $5 copay; Group Sessions for Outpatient Substance Abuse: $5 copay · Out: 5b: 50% coinsurance; 9c1: 50% coinsurance; 9c2: 50% coinsurance
Quick view
Podiatry
In: Podiatry Services: $35 copay; 7f(NMC): $35 copay · Out: 7f: 50% coinsurance; 7f_2: 50% coinsurance
Quick view
Chiropractic
In: Chiropractic Services: $15 copay · Out: 7b: 50% coinsurance
Quick view
Dental
In: Medicare Dental Services: $35 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance · Out: 16a: 50% coinsurance; 16b1: 30% coinsurance; 16b2: 30% coinsurance; 16b4: 30% coinsurance; 16b5: 30% coinsurance; 16c1: 50% coinsurance; 16c2: 50% coinsurance; 16c3: 50% coinsurance; 16c4: 50% coinsurance; 16c7: 50% coinsurance; 16c8: 50% coinsurance; 16c10: 50% coinsurance
Quick view
Vision
In: Eye Exams: $0–$35 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share · Out: 17a: 50% coinsurance; 17a1: 20% coinsurance; 17b: 20% coinsurance; 17b1: $0 cost share; 17b2: $0 cost share; 17b3: $0 cost share; 17b4: $0 cost share; 17b5: $0 cost share
Quick view
Hearing
In: Hearing Exams: $35 copay; Prescription Hearing Aids (all types): $699–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable · Out: 18a: 50% coinsurance; 18a1: $45 copay; 18a2: $45 copay; 18b1: $0 cost share
Quick view
Transportation
In: 10b(NMC): Not applicable · Out: Not separately reported
Quick view
Fitness & wellness
In: Fitness Benefit: $0 cost share · Out: 14c4: 50% coinsurance
Quick view
Over-the-counter allowance
In: Over-the-Counter (OTC) Items: $0 cost share · Out: 13b: $0 cost share
Quick view
Meals
In: Meal Benefit: $0 cost share · Out: 13c: $0 cost share
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-networkPrimary Care Physician Services: $0 cost share
Out-of-network7a: 50% coinsurance
Specialist
In-networkPhysician Specialist Services: $35 copay
Out-of-network7d: 50% coinsurance
Preventive care
In-networkAnnual Physical Exam: $0 cost share; Kidney Disease Education Services: $0 cost share; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share
Out-of-network14b: 50% coinsurance; 14d: 50% coinsurance; 14e1: 50% coinsurance; 14e2: 50% coinsurance; 14e4: 50% coinsurance; 14e5: 50% coinsurance; 14a: 50% coinsurance
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-networkDiagnostic Procedures/Tests: $0–$10 copay
Out-of-network8a1: 50% coinsurance
Laboratory services
In-networkLab Services: $0–$10 copay
Out-of-network8a2: 50% coinsurance
X-rays & standard imaging
In-networkOutpatient X-Ray Services: $45 copay
Out-of-network8b3: 50% coinsurance
MRI, CT & PET imaging
In-networkDiagnostic Radiological Services: $225 copay
Out-of-network8b1: 50% coinsurance
Urgent & hospital care6 benefits
Urgent care
In-networkUrgently Needed Services: $40 copay
Out-of-networkNot separately reported
Emergency room
In-network$130 copay
Out-of-networkNot separately reported
Ground ambulance
In-network$355 copay
Out-of-network$355 copay
Air ambulance
In-network$355 copay
Out-of-network$355 copay
Outpatient hospital
In-networkOutpatient Hospital Services: $0–$325 copay; Observation Services: $325 copay
Out-of-network9a1: 50% coinsurance; 9a2: 50% coinsurance
Outpatient surgery / ASC
In-networkAmbulatory Surgical Center (ASC) Services: $0–$225 copay
Out-of-network9b: 50% coinsurance
Recovery & therapy5 benefits
Home health
In-network$0 cost share
Out-of-network50% coinsurance
Skilled nursing facility
In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $221 / day for days 21–100
Out-of-networkSkilled nursing facility: Tier 1: 50% coinsurance
Cardiac & pulmonary rehabilitation
In-networkCardiac Rehabilitation Services: $15 copay; Intensive Cardiac Rehabilitation Services: $15 copay; Pulmonary Rehabilitation Services: $15 copay; SET for PAD Services: $15 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: 50% coinsurance; 3-2: 50% coinsurance; 3-3: 50% coinsurance; 3-4: 50% coinsurance
Occupational therapy
In-networkOccupational Therapy Services: $15 copay
Out-of-network7c: 50% coinsurance
Physical & speech therapy
In-networkPhysical Therapy and Speech-Language Pathology Services: $15 copay
Out-of-network7i: 50% coinsurance
Behavioral health2 benefits
Mental health services
In-networkPartial Hospitalization Program: $55 copay; Individual Sessions for Mental Health Specialty Services: $5 copay; Group Sessions for Mental Health Specialty Services: $5 copay; Individual Sessions for Psychiatric Services: $5 copay; Group Sessions for Psychiatric Services: $5 copay; Inpatient psychiatric hospital: Tier 1: $260 / day for days 1–6; $0 / day for days 7–90
Out-of-network5a: 50% coinsurance; 7e1: 50% coinsurance; 7e2: 50% coinsurance; 7h1: 50% coinsurance; 7h2: 50% coinsurance; Inpatient psychiatric hospital: Tier 1: 50% coinsurance
Substance use treatment
In-networkIntensive Outpatient Program Services: $55 copay; Individual Sessions for Outpatient Substance Abuse: $5 copay; Group Sessions for Outpatient Substance Abuse: $5 copay
Out-of-network5b: 50% coinsurance; 9c1: 50% coinsurance; 9c2: 50% coinsurance
Specialty care2 benefits
Podiatry
In-networkPodiatry Services: $35 copay; 7f(NMC): $35 copay
Out-of-network7f: 50% coinsurance; 7f_2: 50% coinsurance
Chiropractic
In-networkChiropractic Services: $15 copay
Out-of-network7b: 50% coinsurance
Supplemental benefits7 benefits
Dental
In-networkMedicare Dental Services: $35 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
Out-of-network16a: 50% coinsurance; 16b1: 30% coinsurance; 16b2: 30% coinsurance; 16b4: 30% coinsurance; 16b5: 30% coinsurance; 16c1: 50% coinsurance; 16c2: 50% coinsurance; 16c3: 50% coinsurance; 16c4: 50% coinsurance; 16c7: 50% coinsurance; 16c8: 50% coinsurance; 16c10: 50% coinsurance
Vision
In-networkEye Exams: $0–$35 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share
Out-of-network17a: 50% coinsurance; 17a1: 20% coinsurance; 17b: 20% coinsurance; 17b1: $0 cost share; 17b2: $0 cost share; 17b3: $0 cost share; 17b4: $0 cost share; 17b5: $0 cost share
Hearing
In-networkHearing Exams: $35 copay; Prescription Hearing Aids (all types): $699–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-network18a: 50% coinsurance; 18a1: $45 copay; 18a2: $45 copay; 18b1: $0 cost share
Transportation
Not applicableIn-network10b(NMC): Not applicable
Out-of-networkNot separately reported
Fitness & wellness
In-networkFitness Benefit: $0 cost share
Out-of-network14c4: 50% coinsurance
Over-the-counter allowance
In-networkOver-the-Counter (OTC) Items: $0 cost share
Out-of-network13b: $0 cost share
Meals
In-networkMeal Benefit: $0 cost share
Out-of-network13c: $0 cost share
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · CMS reports a Part B premium reduction of $50 per month.
Maximum out-of-pocket (MOOP)
In-network$6,700
Combined in + out$10,750
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Annual health deductible
$0
Combined network deductible
Not separately reported
Part D premium
Not reported
Network & referrals
Local PPO · Referrals: Not required · Out-of-network coverage: Yes
Prescription drugs0 tiers
Part D deductible
Not reported
Using this plan
Understand H5526-023-000
Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
Freedom Valor (PPO) is a 2027 Local PPO offered by Highmark Blue Cross Blue Shield or Highmark Blue Shield in Western New York. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $2,030 across 7 charged days.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- Primary Care Physician Services: $0 cost share
- Specialist
- Physician Specialist Services: $35 copay
- Laboratory services
- Lab Services: $0–$10 copay
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- Diagnostic Procedures/Tests: $0–$10 copay
- MRI, CT & PET imaging
- Diagnostic Radiological Services: $225 copay
- Outpatient hospital
- Outpatient Hospital Services: $0–$325 copay; Observation Services: $325 copay
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- $130 copay
- Listed inpatient stages
- $2,030 total
7 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Part B premium reduction (“giveback”)
A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports a Part B premium reduction of $50 per month.
Availability
Who can enroll
- Service area
- Western New York (NY)
- Plan type
- Local PPO
- Contract / plan
- H5526-023
- Coverage year
- 2027
Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
DentalMedicare Dental Services: $35 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Restorative Services: 50% coinsurance; Endodontics: 50% coinsurance; Periodontics: 50% coinsurance; Prosthodontics, removable: 50% coinsurance; Prosthodontics, fixed: 50% coinsurance; Oral and Maxillofacial Surgery: 50% coinsurance; Adjunctive General Services: 50% coinsurance
VisionEye Exams: $0–$35 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share
HearingHearing Exams: $35 copay; Prescription Hearing Aids (all types): $699–$999 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Over-the-counter allowanceOver-the-Counter (OTC) Items: $0 cost share
Fitness & wellnessFitness Benefit: $0 cost share
MealsMeal Benefit: $0 cost share
Plan-specific answers
Frequently asked questions
Where is H5526-023-000 available?
Freedom Valor (PPO) is listed for Western New York (NY). Enrollment generally requires Medicare eligibility and residence in the plan's service area.
What is the in-network maximum out-of-pocket limit for H5526-023-000?
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $6,700. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H5526-023-000?
The listed Part C premium is $0 per month. This does not replace the standard Medicare Part B premium.
What does an emergency room visit cost on H5526-023-000?
The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.
Does H5526-023-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness, and other supplemental benefits. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2027
Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.
Plan context
Where H5526-023-000 fits
- Full CMS plan ID
H5526-023-000- Contract
H5526- Base plan code
H5526-023- Segment
000- Carrier
- Highmark Blue Cross Blue Shield or Highmark Blue Shield
- Plan type
- Local PPO
- Service area
- Western New York (NY)
County/service-area foundation
CMS service-area entries
Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.
- Allegany, NY
- Cattaraugus, NY
- Chautauqua, NY
- Erie, NY
- Genesee, NY
- Niagara, NY
- Orleans, NY
- Wyoming, NY
Exact county navigation
Counties with exact segment geography
These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.
About this code
What H5526-023-000 identifies
H5526-023-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H5526-023, H5526 023, or the compact full CMS ID H5526023000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.