2. 2
Table of Contents............................................................2
Important Disclaimers.....................................................3
Plan Presentation ..........................................................4
Medicare Advantage Basics .............................................5
Why Choose Freedom Health?..........................................6
More Benefits & More Savings .........................................7
Visit Our Concierge Office................................................8
Preventive Services.........................................................9
Formulary Information ...................................................10
Prescription Drugs........................................................11
Your Medical Home.......................................................12
Freedom Health Plans ...................................................13
Enrollment ...................................................................14
What to Expect After You Enroll .....................................15
Your Freedom ID Card...................................................16
Benefit Overview...........................................................17
Plan Finder..............................................................18-19
Plan Benefits...........................................................20-27
How to Use Your Benefits and Services......................28-33
Member Portal .............................................................34
Maximum Out of Pocket (MOOP) ....................................35
How to Enroll................................................................36
Over-the-Counter Health Related Supplies ..................37-39
Questions ....................................................................40
Table of Contents
3. 33
Freedom Health is an HMO plan with a Medicare contract and a contract with the Florida Medicaid
program. Enrollment in Freedom Health depends on contract renewal.
This information is not a complete description of benefits. Contact the plan for more information.
Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive
notice when necessary.
You must continue to pay your Medicare Part B premium. Limitations, co-payments and restrictions may
apply. Benefit amounts may vary based on plan and county.
The Part B premium is covered for full dual members of Special Needs Plans.
Our dual eligible Special Needs plans are available to anyone who has both Medical Assistance from the
State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of
Extra Help that you receive.
Our chronic condition Special Needs plan is available to anyone with Medicare who has been diagnosed
with Diabetes, Cardiovascular Disease, Chronic Heart Failure, or Chronic Obstructive Pulmonary Disease
(COPD).
Freedom Health is accredited by the National Committee for Quality Assurance. NCQA Health Plan
Accreditation evaluates how well a health plan manages all parts of its delivery system --physicians,
hospitals, other providers and administrative services -- in order to continuously improve the quality of
care and services provided to its members.
Freedom Health has been approved by the National Committee for Quality Assurance (NCQA) to operate
a Special Needs Plan (SNP) until 2018 based on a review of Freedom Health’s Model of Care.
A sales person will be present with information and applications. For accommodation of persons with
special needs at sales meetings call 1-888-796-0946, TTY: 711.
HMO eligible beneficiaries may enroll in the plan only during specific times of the year.
HMO-SNP eligible beneficiaries can enroll at any time.
Contact the Plan for more information at the number listed on the back page.
Important Dates
each year
October 1:
Oct 15 – Dec 7:
Important Disclaimers
4. 4
Name of Benefit Consultant: _________________________
Prospective Members: please write the name of the plan representative with
whom you are meeting.
This Presentation will cover Freedom Health’s Medicare
Advantage HMO Plans and Medicare Advantage HMO Special
Needs Plans and will highlight the following information:
Your Current Medicare Coverage
Comparing Medicare Advantage to Original Medicare
Freedom’s Benefit Plan Options
Choosing the Best Plan for You
How to Enroll in a Freedom Health Medicare Advantage
HMO Plan or HMO-SNP Plan
Plan Presentation
5. 5
What is Medicare?
Medicare is federal health
insurance for:
people 65 and older,
younger people with certain
disabilities, and
people with end-stage renal
disease
(with limited exceptions).
Medicare Advantage Basics - Are you Eligible?
You must have both Medicare parts “A” and “B”.
You must be a permanent resident in the area
where the plan is offered.
People with End Stage Renal Disease are not
eligible for Medicare Advantage (with limited
exceptions).
6. 6
Why Ch se Freedom Health?
Freedom Health is...
Owned and operated by doctors
Focused on preventive care
Headquartered in Tampa, FL
Accredited by NCQA with a
“Commendable” rating.
An HMO plan with a Medicare
contract and a contract with the
Florida Medicaid program.
4.0 Overall Medicare Star Rating*
1
2
3
4
5
6
7. 7
More Benefits + More Savings = Better Value!
Here are some of the best reasons to join!
Receive a monthly over-the-counter allowance from $10 to $45
each month based on plan selection. That’s a savings between
$120 and $540 over the course of a year! Easy online ordering
or phone your order in! Your order is shipped to you at no cost.
Get a SilverSneakers®
Fitness Membership at no cost to you!
With access to thousands of locations, you will have use of the
equipment, pools, saunas and other amenities. You can also
order a SilverSneakers®
Steps home fitness kit if that is more
convenient!
Save with a Part B premium refund on select plans. That’s a
savings between $36 to $80 each month or between $432
to $960 over the course of a year applied back to your social
security check!
Valuable Vision, Dental and Hearing benefits.
Receive between 4 and 12 one way Transportation trips on our
Freedom Medicare, Platinum or Chronic SNP plans depending
on the plan. Our Dual SNP plans offer 12 round transportation
trips.
Stay healthier with an array of Preventive Services at NO COST
to YOU! Receive an Annual Wellness Visit, screenings, vaccines
and many other services to keep you on track.
Brand and Generic prescription drug coverage is available on
plans that offer part “D” coverage. Gap coverage is available on
select plans.
With our home delivery pharmacy, you will receive 3 months
supply for 2 months copay on most plans with prescription drug
coverage. Easy ordering and delivery within 10 days. You can
also sign up for automated mail order delivery.
8. 8
Visit our Concierge Offices
Hillsborough/Pinellas/Polk
5403 N. Church Ave., Tampa
Toll Free: 1-888-211-9918
Indian River/Martin/St. Lucie
1187 S. US Hwy. 1, Vero Beach
Toll Free: 1-888-274-8575
Lake/Marion/Sumter/Volusia
2102 SW 20th Pl.,Building 200,
Suite 201, Ocala
Toll Free: 1-888-420-2539
www.freedomhealth.com.
Brevard/Orange/Osceola/Seminole
950 S. Winter Park Dr., Suite 340, Casselberry
Toll Free: 1-888-364-7905
Charlotte/Manatee/Sarasota
3874 E. SR 64, Bradenton
Toll Free: 1-888-850-5315
Citrus/Hernando/Pasco
8373 Northcliffe Blvd., Spring Hill
Toll Free: 1-888-211-9921
Collier/Lee
6831 Palisades Park Ct., Suite 1, Ft. Myers
Toll Free: 1-888-272-2992
Our Local Concierge Centers Offer:
(replacement cards, PCP changes, etc.)
Member Services: TTY: 711
Healthcare is local – whether it’s your doctor, your specialist, or your insurance
provider. We’re headquartered in Tampa, Florida with local concierge centers
throughout the State.
Visit or Call Us at a Location Near You
Concierge Hours of Operation: 8am - 5pm,
Monday - Friday
10. 10
Formulary Information
The plan has four (4) cost-sharing tiers. Every drug on the plan’s Drug List is in one of
four cost-sharing tiers. To find out which cost-sharing tier your drug is in, look it up in
the plan’s Formulary. Then refer to the benefits section for plan-specific cost-sharing.
How do you find your drugs in the Formulary?
There are two ways to find your drug within the formulary:
1) Alphabetical Listing
The Index of the Formulary provides an alphabetical list of all
of the drugs along with the page number where you can find
coverage information.
2) Medical Condition
Drugs in the formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category “Cardiovascular
Agents”.
Initial Coverage Stage Drug Costs
Formulary(List of Covered Drugs)
PBP Plan Name
078 Freedom Medi-Medi Partial (HMO SNP)
087 Freedom Medi-Medi Full (HMO SNP)
11. 11
Prescription Drugs
How Much Do You Pay for Prescription Drugs?
Stage 3
Catastrophic
Coverage Stage
Once you have paid
enough for your drugs
to move onto this last
payment stage, the plan
will pay most of the cost
of your drugs for the
rest of the year.(2)
Stage 1
Initial Coverage Stage
The plan pays its
share of the cost of your
drugs and you pay your
share of the cost.
You stay in this stage
until your payments for
the year plus the plan’s
payments total $3,310.
Stage 2
Coverage Gap Stage/
Donut Hole
You pay 58% of the
generic drug cost and
the discounted cost for
brand drugs until the
yearly out-of-pocket drug
cost reaches $4,850,
unless you are already
getting Medicare Extra
Help.(1)
12. 12
Your Network Primary Care Provider (PCP) coordinates all of your
care. A network PCP is considered your “medical home”.
Benefits of a Medical Home
Your Medical Home
Hospital
Ancillary
DME Supplies Pharmacy
Wellness
Services
Network Specialist
Network PCP
13. Freedom Health Plans
The Freedom Health Medicare Advantage HMO are plans with and without
prescription drug coverage that offer many valuable benefits.
Freedom Health also offers two types of Special Needs Plans (SNPs). If you
qualify to join a Medicare SNP, you get all of your Medicare hospital and
medical health care services through the plan, including Medicare prescription
drug coverage:
with drug
coverage are plans available to anyone who has both Medical Assistance
from the State and Medicare. Premiums, co-pays, co-insurance, and
deductibles may vary based on the level of Extra Help you receive.
with drug coverage
are plans for those individuals who have been diagnosed with chronic or
disabling conditions such as:
Freedom Health has a plan for you!
- Cardiac Arythmias
- Coronary Artery Disease
- Peripheral Vascular Disease
- Chronic Venous Thromboembolic
Disorder
- COPD
- Bronchitis
- Asthma
- Pulmonary Fibrosis
13
14. 14
Enrollment
eligible individuals may enroll or end their enrollment in a MA plan. The AEP
occurs October 15th through December 7th of each year.
following January 1st of each year.
the year.
may be able to enroll with an earlier effective date.
Please call our Member Services
department for more information
or refer to the “Medicare & You”
handbook for more information on
enrollment periods. You can review
this handbook on the web by visiting:
www.medicare.gov/publications/
15. 15
What to Expect After You Enroll
You will receive a Freedom Health welcome packet
and other plan materials that include:
(Material covers may vary)
FRH12KITENV
P.O. Box 151137, Tampa, FL 33684
www.freedomhealth.com
Address Service Requested
2015
Evidence of Coverage
5
ge
2015 Provider andPharmacy Directory
Formulary
(List of Covered Drugs)
PBP Plan Name078 Freedom Medi-Medi Partial (HMO SNP)
087 Freedom Medi-Medi Full (HMO SNP)
ID: <0000000000> <0000>
<FIRST><MI><LAST>
Eff. Date: <Insert date>
PCP: <John Doe, M.D.>
Phone: <555-555-5555>
RxBIN#: 610011 RxPCN#: IRX
RxGrp#: MPDH5427 Issuer#: 80840
RxID#: <Insert member ID#>
Member Since
H5427 – PBP<number>
SAMPLE00000000> <0
T><MI <LAST>
M
16. 16
ID: <0000000000> <0000>
<FIRST><MI><LAST>
Eff. Date: <Insert date>
PCP: <John Doe, M.D.>
Phone: <555-555-5555>
RxBIN#: 610011 RxPCN#: FRH
RxGrp#: MPDH5427 Issuer#: 80840
RxID#: <Insert member ID#>
Member Since
H5427 – PBP<number>
Identifies your plan
benefits for your
pharmacist
Your Freedom
identification number
The year you joined
Freedom Health
Name of your Freedom
Medicare Advantage
Plan
Your Plan Number
Up-front payments for
the plan benefits you
receive
Member Services
Toll-Free Number
Information for your
doctor, pharmacist or
hospital
<Freedom Plan Name>
Member Services: 1-800-401-2740
TTY/TDD: 1-800-955-8771 www.freedomhealth.com
Behavioral Health: <X-XXX-XXX-XXXX>
Provider Services (UM): <X-XXX-XXX-XXXX>
Pharmacy Technical Support: <X-XXX-XXX-XXXX>
Part D Prior Authorization: <X-XXX-XXX-XXXX>
Submit Claims to:
Freedom Health
Claims Department
P.O. Box 151348
Tampa FL 33684
EDI Payer ID: XXXXX
Urgent Care: <$>
ER: <$>
Your Freedom ID Card
SAMP00000000
T><MI><LAST>AMPLE0000> <
SAMPPLEP
SAMPLE
: 1-800-401-27
1-800-955-877 www.freedomh
lth: XXASAMPLSA
17. 17
Our Representative will show you the
specifics of your Freedom Health Medicare
Advantage plan benefits, using the Plan
Overview and the 2016 Formulary.
2016
Benefits
Benefit Overview
18. 18
Plan Type MAPD
Plan Name Freedom Medicare Plan Rx Freedom Platinum Plan Rx
Freedom VIP
Care
F
HMO HMO HMO-SNP
Plan ID#
County
059 060 088 089 091 092 093 094 070
Brevard X
Broward X
Charlotte X
Citrus X X X
Collier
Hernando X X
Hillsborough X X
Indian River X X
Lake X X X
Lee X
Manatee X X X
Marion X X X
Martin X
Miami-Dade X X
Orange X X X
Osceola X X X
Palm Beach X X
Pasco X X
Pinellas X X
Polk X X
Sarasota X X
Seminole X X X
St. Lucie X X
Sumter X X X
Volusia X
Plan Finder Chart
19. 19
Find a plan in your county
CSNP MA DSNP
P Freedom VIP
Savings
Freedom VIP
Savings COPD
Freedom VIP
Savings
Freedom VIP
Savings COPD
Freedom Savings
Plan
Freedom
Medi-Medi Partial
Freedom
Medi-Medi Full
HMO-SNP HMO-SNP HMO-SNP HMO-SNP HMO HMO-SNP
072 077 082 083 052 078 087
X X X X
X X X X
X X X X
X X X X X
X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
20. 20
PBP Number 059 060 088
Premium $0 $0 $0
Part B Buydown $0.00 $0.00 $0.00
Max out of Pocket $3,400 $3,400 $3,400
INPATIENT CARE
Inpatient Hospital $250 days 1-7
$0 days 8-90
$195 days 1-7
$0 days 8-90
$125 days 1-7
$0 days 8-90
Inpatient Mental $250 days 1-7
$0 days 8-90
$195 days 1-7
$0 days 8-90
$125 days 1-7
$0 days 8-90
Skilled Nursing Facility $0 days 1-5
$40 days 6-20
$150 days 21-100
$0 days 1-5
$40 days 6-20
$150 days 21-100
$0 days 1-5
$40 days 6-20
$150 days 21-100
OUTPATIENT CARE
Primary Care Visit $0 $0 $0
Specialist Visit $50 $50 $35
Chiropractor Visit $20 $20 $15
Podiatry Visit $50 $50 $35
Outpatient Mental Health $40 $40 $35
Outpatient Substance Abuse $50-$250 $50-$250 $35-$250
Ambulatory Surgery Center Visit $85 $85 $25
Outpatient Hospital Visit $250 $250 $250
Ambulance $200 $200 $200
Emergency Care $75 $75 $75
Worldwide ER Care $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit
Urgently Needed Care $10 $10 $10
Occupational Therapy $40 $40 $35
Physical Therapy $40 $40 $35
Speech Therapy $40 $40 $35
Home Health $10 $20 $10
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
Durable Medical Equipment (DME) 20% 20% 20%
Prosthetic Devices 20% 20% 20%
Diabetes Monitoring Training $0 $0 $0
Diabetes Nutrition Therapy $0 $0 $0
Diabetes Supplies 0-20% 0-20% 0-20%
Laboratory (Outpatient) $0 $0 $0
Diagnostic Procedures/Tests $0 $0 $0
X-rays $0 $0 $0
Diagnostic Radiology $25-$200 $25-$200 $25-$150
Therapeutic Radiology 20% 20% 20%
PREVENTIVE SERVICES
Bone Mass Measurement $0 $0 $0
Colorectal Screening $0 $0 $0
Flu Vaccine $0 $0 $0
Pneumonia Vaccine $0 $0 $0
Freedom Medicare Plan RX (HMO) Freedom Platinum Plan RX (HMO)Freedom Medicare Plan RX (HMO)Plan Name
21. 21
*You pay 58% of generic drug cost and discounted cost for brand drug until the yearly out-of-pocket drug cost reaches $4,850, unless you are already getting Medicare Extra
Help. Some plans have $0 and some plans have $5 co-pay for Tier 1 during the Coverage Gap/Donut Hole. **Cost Sharing varies based on Medicaid status.
Hepatitis B Vaccine $0 $0 $0
Mammograms $0 $0 $0
Pap Smears/Pelvic Exams $0 $0 $0
Prostate Cancer Screening $0 $0 $0
Renal Dialysis 20% 20% 20%
ESRD Nutrition Therapy $0 $0 $0
Annual Wellness Visit $0 $0 $0
PART B DRUGS
Part B Drugs (not Chemo) 20% 20% 20%
Part B Chemo Drugs 20% 20% 20%
PART D DRUGS
Deductible $0 $0 $0
ICL Limit $3,310 $3,310 $3,310
Tier 1 Preferred Generic $0 $0 $0
Tier 2 Preferred Brand $45 $45 $30
Tier 3 Non-Preferred Brand $95 $95 $95
Tier 4 Specialty 33% 33% 33%
Mail Order 3 months for 2 copays 3 months for 2 copays 3 months for 2 copays
GAP Coverage* Tier 1 $5 copay Tier 1 $5 copay Tier 1
DENTAL
Medicare-Covered Dental $0 $0 $0
Oral Exam $0 1/yr $0 1/yr $0 1/yr
Routine Dental Cleaning $0 2/yr $0 2/yr $0 2/yr
Fluoride Treatment $0 1/yr $0 1/yr $0 1/yr
Dental X-ray $5-$75 $5-$75 $5-$75
Comprehensive Dental No No No
HEARING
Hearing Aids $0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
Hearing Aid Fitting/Eval $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
Medicare-Covered Hearing $0 $0 $0
Routine Hearing Exam $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
VISION
Glasses/Contacts - Cat Surg $15 $15 $15
Routine Eye Exam $0 $0 $0
Glasses $15 1/yr $15 1/yr $15 1/yr
Contacts $15 1/yr $15 1/yr $15 1/yr
Eyewear Limit $100 $100 $100
SUPPLEMENTAL BENEFITS
Health Club Yes Yes Yes
Transportation $0 4 one-way trips $0 4 one-way trips $0 4 one-way trips
Over-the-Counter (OTC) Supplies $15 $15 $40
No No No
22. 22
Plan Name
PBP Number 089 091 092 093 094
Premium $0 $0 $0 $0 $0
Part B Buydown $0.00 $0.00 $0.00 $0.00 $0.00
Max out of Pocket $3,400 $3,400 $3,400 $3,400 $3,400
INPATIENT CARE
Inpatient Hospital $110 days 1-7
$0 days 8-90
$125 days 1-7
$0 days 8-90
$150 days 1-7
$0 days 8-90
$95 days 1-7
$0 days 8-90
$125 days 1-7
$0 days 8-90
Inpatient Mental $110 days 1-7
$0 days 8-90
$125 days 1-7
$0 days 8-90
$150 days 1-7
$0 days 8-90
$95 days 1-7
$0 days 8-90
$125 days 1-7
$0 days 8-90
Skilled Nursing Facility $0 days 1-5
$40 days 6-20
$125 days 21-100
$0 days 1-5
$40 days 6-20
$150 days 21-100
$0 days 1-5
$40 days 6-20
$150 days 21-100
$0 days 1-5
$40 days 6-20
$125 days 21-100
$0 days 1-5
$40 days 6-20
$100 days 21-100
OUTPATIENT CARE
Primary Care Visit $0 $0 $0 $0 $0
Specialist Visit $30 $35 $35 $30 $25
Chiropractor Visit $20 $20 $20 $20 $20
Podiatry Visit $30 $35 $35 $30 $25
Outpatient Mental Health $30 $35 $35 $30 $25
Outpatient Substance Abuse $30-$200 $35-$250 $35-$200 $30-$200 $25-$200
Ambulatory Surgery Center Visit $25 $50 $50 $25 $25
Outpatient Hospital Visit $200 $250 $200 $200 $200
Ambulance $175 $195 $175 $175 $155
Emergency Care $75 $75 $75 $75 $75
Worldwide ER Care $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit
Urgently Needed Care $10 $10 $10 $10 $10
Occupational Therapy $30 $35 $35 $30 $25
Physical Therapy $30 $35 $35 $30 $25
Speech Therapy $30 $35 $35 $30 $25
Home Health $10 $10 $10 $10 $10
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
Durable Medical Equipment (DME) 20% 20% 20% 20% 20%
Prosthetic Devices 20% 20% 20% 20% 20%
Diabetes Monitoring Training $0 $0 $0 $0 $0
Diabetes Nutrition Therapy $0 $0 $0 $0 $0
Diabetes Supplies 0-20% 0-20% 0-20% 0-20% 0-20%
Laboratory (Outpatient) $0 $0 $0 $0 $0
Diagnostic Procedures/Tests $0 $0 $0 $0 $0
X-rays $0 $0 $0 $0 $0
Diagnostic Radiology $25-$150 $25-$150 $25-$150 $25-$150 $25-$150
Therapeutic Radiology 20% 20% 20% 20% 20%
PREVENTIVE SERVICES
Bone Mass Measurement $0 $0 $0 $0 $0
Colorectal Screening $0 $0 $0 $0 $0
Flu Vaccine $0 $0 $0 $0 $0
Pneumonia Vaccine $0 $0 $0 $0 $0
Freedom Platinum Plan
RX (HMO)
Freedom Platinum Plan
RX (HMO)
Freedom Platinum Plan
RX (HMO)
Freedom Platinum Plan
RX (HMO)
Freedom Platinum Plan
RX (HMO)
23. 23
*You pay 58% of generic drug cost and discounted cost for brand drug until the yearly out-of-pocket drug cost reaches $4,850, unless you are already getting Medicare Extra
Help. Some plans have $0 and some plans have $5 co-pay for Tier 1 during the Coverage Gap/Donut Hole. **Cost Sharing varies based on Medicaid status.
Hepatitis B Vaccine $0 $0 $0 $0 $0
Mammograms $0 $0 $0 $0 $0
Pap Smears/Pelvic Exams $0 $0 $0 $0 $0
Prostate Cancer Screening $0 $0 $0 $0 $0
Renal Dialysis 20% 20% 20% 20% 20%
ESRD Nutrition Therapy $0 $0 $0 $0 $0
Annual Wellness Visit $0 $0 $0 $0 $0
PART B DRUGS
Part B Drugs (not Chemo) 20% 20% 20% 20% 20%
Part B Chemo Drugs 20% 20% 20% 20% 20%
PART D DRUGS
Deductible $0 $0 $0 $0 $0
ICL Limit $3,310 $3,310 $3,310 $3,310 $3,310
Tier 1 Preferred Generic $0 $0 $0 $0 $0
Tier 2 Preferred Brand $35 $35 $30 $30 $30
Tier 3 Non-Preferred Brand $85 $80 $80 $69 $80
Tier 4 Specialty 33% 33% 33% 33% 33%
Mail Order 3 months for 2 copays 3 months for 2 copays 3 months for 2 copays 3 months for 2 copays 3 months for 2 copays
GAP Coverage* Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
DENTAL
Medicare-Covered Dental $0 $0 $0 $0 $0
Oral Exam $0 1/yr $0 1/yr $0 1/yr $0 1/yr $0 1/yr
Routine Dental Cleaning $0 2/yr $0 2/yr $0 2/yr $0 2/yr $0 2/yr
Fluoride Treatment $0 1/yr $0 1/yr $0 1/yr $0 1/yr $0 1/yr
Dental X-ray $5-$75 $5-$75 $5-$75 $5-$75 $5-$75
Comprehensive Dental No No No No No
HEARING
Hearing Aids $0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
Hearing Aid Fitting/Eval $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
Medicare-Covered Hearing $0 $0 $0 $0 $0
Routine Hearing Exam $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
VISION
Glasses/Contacts - Cat Surg $15 $15 $15 $15 $15
Routine Eye Exam $0 $0 $0 $0 $0
Glasses $15 1/yr $15 1/yr $15 1/yr $15 1/yr $15 1/yr
Contacts $15 1/yr $15 1/yr $15 1/yr $15 1/yr $15 1/yr
Eyewear Limit $100 $100 $100 $100 $100
SUPPLEMENTAL BENEFITS
Health Club Yes Yes Yes Yes Yes
Transportation $0 4 one-way trips $0 4 one-way trips $0 4 one-way trips $0 4 one-way trips $0 4 one-way trips
Over-the-Counter (OTC) Supplies $35 $25 $25 $25 $30
No No No No No
24. 24
PBP Number 070 072 077 082 083
Premium $0 $0 $0 $0 $0
Part B Buydown $0.00 $80.00 $61.00 $36.00 $0.00
Max out of Pocket $3,400 $3,400 $3,400 $6,700 $6,700
INPATIENT CARE
Inpatient Hospital $90 days 1-7
$0 days 8-90
$205 days 1-7
$0 days 8-90
$195 days 1-7
$0 days 8-90
$250 days 1-7
$0 days 8-90
$250 days 1-7
$0 days 8-90
Inpatient Mental $90 days 1-7
$0 days 8-90
$205 days 1-7
$0 days 8-90
$195 days 1-7
$0 days 8-90
$250 days 1-6
$0 days 7-90
$250 days 1-6
$0 days 7-90
Skilled Nursing Facility $0 days 1-5
$40 days 6-20
$125 days 21-100
$0 days 1-5
$40 days 6-20
$150 days 21-100
$0 days 1-5
$40 days 6-20
$150 days 21-100
$0 days 1-20
$150 days 21-100
$0 days 1-20
$150 days 21-100
OUTPATIENT CARE
Primary Care Visit $0 $0 $0 $0 $0
Specialist Visit $25 $30 $30 $40 $45
Chiropractor Visit $20 $20 $20 $20 $20
Podiatry Visit $25 $30 $30 $40 $45
Outpatient Mental Health $25 $30 $30 $40 $40
Outpatient Substance Abuse $25-$200 $30-$250 $30-$250 $40-$250 $45-$250
Ambulatory Surgery Center Visit $0 $50 $50 $100 $100
Outpatient Hospital Visit $200 $250 $250 $250 $250
Ambulance $150 $175 $150 $150 $175
Emergency Care $75 $75 $75 $75 $75
Worldwide ER Care $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit
Urgently Needed Care $10 $10 $10 $10 $10
Occupational Therapy $25 $30 $30 $40 $40
Physical Therapy $25 $30 $30 $40 $40
Speech Therapy $25 $30 $30 $40 $40
Home Health $0 $0 $0 $0 $0
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
Durable Medical Equipment (DME) 20% 20% 0-20% *Oxygen $0 20% 0-20% *Oxygen $0
Prosthetic Devices 20% 20% 20% 20% 20%
Diabetes Monitoring Training $0 $0 $0 $0 $0
Diabetes Nutrition Therapy $0 $0 $0 $0 $0
Diabetes Supplies 0% 0% 0-20% 0% 0-20%
Laboratory (Outpatient) $0 $0 $0 $0 $0
Diagnostic Procedures/Tests $0 $0 $0 $0 $0
X-rays $0 $0 $0 $0 $0
Diagnostic Radiology $25-$125 $25-$150 $25-$150 $25-$200 $25-$200
Therapeutic Radiology 20% 20% 20% 20% 20%
PREVENTIVE SERVICES
Bone Mass Measurement $0 $0 $0 $0 $0
Colorectal Screening $0 $0 $0 $0 $0
Flu Vaccine $0 $0 $0 $0 $0
Pneumonia Vaccine $0 $0 $0 $0 $0
Freedom VIP Care
(HMO-SNP)
Freedom VIP Savings
(HMO-SNP)
Freedom VIPSavings COPD
(HMO-SNP)
Freedom VIP Savings
(HMO-SNP)
Freedom VIPSavings COPD
(HMO-SNP)
25. 25
*You pay 58% of generic drug cost and discounted cost for brand drug until the yearly out-of-pocket drug cost reaches $4,850, unless you are already getting Medicare Extra
Help. Some plans have $0 and some plans have $5 co-pay for Tier 1 during the Coverage Gap/Donut Hole. **Cost Sharing varies based on Medicaid status.
Hepatitis B Vaccine $0 $0 $0 $0 $0
Mammograms $0 $0 $0 $0 $0
Pap Smears/Pelvic Exams $0 $0 $0 $0 $0
Prostate Cancer Screening $0 $0 $0 $0 $0
Renal Dialysis 20% 20% 20% 20% 20%
ESRD Nutrition Therapy $0 $0 $0 $0 $0
Annual Wellness Visit $0 $0 $0 $0 $0
PART B DRUGS
Part B Drugs (not Chemo) 20% 20% 20% 20% 20%
Part B Chemo Drugs 20% 20% 20% 20% 20%
PART D DRUGS
Deductible $0 $0 $0 $0 $0
ICL Limit $3,310 $3,310 $3,310 $3,310 $3,310
Tier 1 Preferred Generic $0 $0 $0 $0 $0
Tier 2 Preferred Brand $25 $35 $35 $40 $40
Tier 3 Non-Preferred Brand $75 $80 $80 $90 $90
Tier 4 Specialty 33% 33% 33% 33% 33%
Mail Order 3 months for 2 copays 3 months for 2 copays 3 months for 2 copays 3 months for 2 copays 3 months for 2 copays
GAP Coverage* Tier 1 Tier 1 $5 Tier 1 $5 Tier 1 $5 Tier 1 $5
DENTAL
Medicare-Covered Dental $0 $0 $0 $0 $0
Oral Exam $0 1/yr $0 1/yr $0 1/yr $0 1/yr $0 1/yr
Routine Dental Cleaning $0 2/yr $0 2/yr $0 2/yr $0 2/yr $0 2/yr
Fluoride Treatment $0 1/yr $0 1/yr $0 1/yr $0 1/yr $0 1/yr
Dental X-ray $5-$75 $5-$75 $5-$75 $5-$75 $5-$75
Comprehensive Dental No No No No No
HEARING
Hearing Aids $0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
Hearing Aid Fitting/Eval $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
Medicare-Covered Hearing $0 $0 $0 $0 $0
Routine Hearing Exam $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
VISION
Glasses/Contacts - Cat Surg $15 $15 $15 $15 $15
Routine Eye Exam $0 $0 $0 $0 $0
Glasses $15 1/yr $15 1/yr $15 1/yr $15 1/yr $15 1/yr
Contacts $15 1/yr $15 1/yr $15 1/yr $15 1/yr $15 1/yr
Eyewear Limit $100 $100 $100 $100 $100
SUPPLEMENTAL BENEFITS
Health Club Yes Yes Yes Yes Yes
Transportation $0 8 one-way trips $0 8 one-way trips $0 8 one-way trips $0 8 one-way trips $0 8 one-way trips
Over-the-Counter (OTC) Supplies $40 $40 $40 $45 $35
Yes, After INP acute sty Yes, After INP acute sty Yes, After INP acute sty Yes, After INP acute sty Yes, After INP acute sty
26. 26
PBP Number 052 078 087
Premium $0 $28.00 $28.00
Part B Buydown $65.00 $0.00 $0.00
Max out of Pocket $3,400 $3,400 $3,400
INPATIENT CARE
Inpatient Hospital $245 days 1-7
$0 days 8-90
$0 $0
Inpatient Mental $245 days 1-7
$0 days 8-90
$0 $0
Skilled Nursing Facility** $0 days 1-5
$40 days 6-20
$125 days 21-100
$0 days 1-100 $0
OUTPATIENT CARE
Primary Care Visit $0 $0 $0
Specialist Visit $45 $0 $0
Chiropractor Visit $20 $0 $0
Podiatry Visit $45 $0 $0
Outpatient Mental Health $40 $0 $0
Outpatient Substance Abuse $45-$250 $0 $0
Ambulatory Surgery Center Visit $100 $0 $0
Outpatient Hospital Visit $250 $0 $0
Ambulance** $175 $0 $0
Emergency Care** $75 $0 $0
Worldwide ER Care $500 copay; $25,000 limit $500 copay; $25,000 limit $500 copay; $25,000 limit
Urgently Needed Care $10 $0 $0
Occupational Therapy $40 $0 $0
Physical Therapy $40 $0 $0
Speech Therapy $40 $0 $0
Home Health $10 $0 $0
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
Durable Medical Equipment (DME)** 20% 0% 0%
Prosthetic Devices** 20% 0% 0%
Diabetes Monitoring Training $0 $0 $0
Diabetes Nutrition Therapy $0 $0 $0
Diabetes Supplies 0-20% 0% 0%
Laboratory (Outpatient) $0 $0 $0
Diagnostic Procedures/Tests $0 $0 $0
X-rays $0 $0 $0
Diagnostic Radiology $25-$150 0% 0%
Therapeutic Radiology** 20% 0% or 20% 0%
PREVENTIVE SERVICES
Bone Mass Measurement $0 $0 $0
Colorectal Screening $0 $0 $0
Flu Vaccine $0 $0 $0
Pneumonia Vaccine $0 $0 $0
Freedom Savings Plan (HMO) Freedom Medi-Medi Full (HMO-SNP)Freedom Medi-Medi Partial (HMO-SNP)
27. 27
*You pay 58% of generic drug cost and discounted cost for brand drug until the yearly out-of-pocket drug cost reaches $4,850, unless you are already getting Medicare Extra
Help. Some plans have $0 and some plans have $5 co-pay for Tier 1 during the Coverage Gap/Donut Hole. **Cost Sharing varies based on Medicaid status.
Hepatitis B Vaccine $0 $0 $0
Mammograms $0 $0 $0
Pap Smears/Pelvic Exams $0 $0 $0
Prostate Cancer Screening $0 $0 $0
Renal Dialysis** 20% 0% or 20% 0%
ESRD Nutrition Therapy $0 $0 $0
Annual Wellness Visit $0 $0 $0
PART B DRUGS
Part B Drugs (not Chemo)** 20% 0% or 20% 0%
Part B Chemo Drugs** 20% 0% or 20% 0%
PART D DRUGS
Deductible
ICL Limit
Tier 1 Preferred Generic
Tier 2 Preferred Brand
Tier 3 Non-Preferred Brand
Tier 4 Specialty
Mail Order
GAP Coverage*
DENTAL
Medicare-Covered Dental $0 $0 $0
Oral Exam $0 1/yr $0 1/yr $0 1/yr
Routine Dental Cleaning $0 2/yr $0 2/yr $0 2/yr
Fluoride Treatment $0 2/yr $0 2/yr $0 2/yr
Dental X-ray $0-75 $0-75 $0-75
Comprehensive Dental No Yes Yes
HEARING
Hearing Aids $0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
$0 for 1 aid; 1 aid /2yrs
$500 limit
Hearing Aid Fitting/Eval $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
Medicare-Covered Hearing $0 $0 $0
Routine Hearing Exam $0 1 every 2 yrs $0 1 every 2 yrs $0 1 every 2 yrs
VISION
Glasses/Contacts - Cat Surg $10 $0 $0
Routine Eye Exam $0 $0 $0
Glasses $10 1/yr $0 1/yr $0 1/yr
Contacts $10 1/yr $0 1/yr $0 1/yr
Eyewear Limit $100 $100 $100
SUPPLEMENTAL BENEFITS
Health Club Yes Yes Yes
Transportation $0 4 one-way trips $0 12 round-way trips $0 12 round-way trips
Over-the-Counter (OTC) Supplies $10 $30 $15
No Yes, After INP acute sty Yes, After INP acute sty
by LIS Level
by LIS Level
28. 28
How to Use Your Benefits and Services
Member Services
Contact us at 1-800-401-2740. TTY users: 711,
8am - 8pm 7 days a week from Oct 1 - Feb 14 and
8am - 8pm Monday-Friday from Feb 15 - Sept 30.
Chiropractic
For Chiropractors, call our Member Services
department or talk to your PCP for chiropractic
questions.
Dental, Vision &
Hearing
Freedom partners with Argus Dental for both Dental
and Vision services. Please call Member Services
for a provider listing, or review providers at www.
argusdentalvision.com. Hearing services are provided
by HearUSA. They can be contacted at 1-800-333-
3389.
Freedom has partnered with SilverSneakers®
to
all of our plans. Please visit their website at www.
silversneakers.com or call our Member Services
department for the most updated participating network
Please take your Freedom ID to the participating
Lab Services
Freedom Health partners with Quest Diagnostics to
provide clinical laboratory services. Call them directly
at 1-800-377-8448. TTY/TDD users call 711 or visit
their website at www.questdiagnostics.com for a
location near you.
Over-the-Counter
Health Related
Supplies
may contact us directly. A list of available supplies
are on page 37, along with ordering information. You
will receive supplies in approximately 7-10 business
days after you submit your order.
Podiatry
Participating podiatrists are listed in the Provider
Directory. Call our Member Services department or
talk to your PCP for podiatry questions.
Service How to Find It?
While you must stay within our network of providers, these companies were chosen through a
29. 29
Using Your Plan: Vision Benefits
All of our plans also offer vision
after each cataract surgery that includes
insertion of an intraocular lens. Corrective
lenses/frames (and replacements) needed
after cataract removal without a lens implant.
(continued on next page)
Vision Benefits
Freedom Savings Plan
(HMO): 052
Freedom Medi-Medi Partial
(HMO SNP): 078
Freedom Medi-Medi Full
(HMO SNP): 087
Freedom Medicare Plan Rx (HMO):
059, 060
Freedom VIP Care (HMO SNP): 070
Freedom VIP Savings (HMO SNP):
072, 082
Freedom VIP Savings COPD
(HMO SNP): 077, 083
Freedom Platinum Plan Rx (HMO):
088, 089, 091, 092, 093, 094
Covered
Services
Co-Pays Co-Pays Co-Pays
Eye Exams
31. Dental Benefits
Freedom Savings Plan
(HMO): 052
Freedom Medi-Medi Partial
(HMO SNP): 078
Freedom Medi-Medi Full
(HMO SNP): 087
Freedom Medicare Plan Rx
(HMO): 059, 060
Freedom VIP Care (HMO SNP): 070
Freedom VIP Savings
(HMO SNP): 072, 082
Freedom VIP Savings COPD
(HMO SNP): 077, 083
Freedom Platinum Plan Rx (HMO):
088, 089, 091, 092, 093, 094
Covered Services Co-Pays Co-Pays Co-Pays
(continued on next page) (continued on next page) continued on next page)
31
Using Your Plan: Dental Benefits
We all want a great smile, so all of our plans offer
include:
dental provider)
(excludes periodontal scaling, root planing and periodontal
maintenance)
33. 33
Using Your Plan: Hearing Benefits
on most plans:
years.
years.
featuring choice of style and
technologies.
Hearing Benefits
All Plans
Covered Services Co-Pays
Diagnostic Hearing
Exam
Routine Hearing Exam
Hearing Aids
34. Register & Do More Online
with our Member Portal!
Here are some of the benefits you will receive:
Place & track orders
for your over-the-
counter medication
and diabetic supplies.
Print and order your
ID CARD, provider
directory, formulary
and other Plan
materials.
View your claims
information.
Track your out-of-
pocket expenses.
(MOOP)
Personal
Health Tracker
Find a Plan Doctor,
Pharmacy, Hospital
and covered drug.
Gain access to
health & wellness
information.
Access important Plan
forms and documents
from central location.
Complete your Health
Assessment Form
NEW!
NEW!
34
35. 35
Inpatient Services
Outpatient Services
Services
Services (OT, PT, & ST)
Outpatient Medical
Services & Supplies
Training
Pneumonia)
Exams
The following services / benefits count towards your maximum out-of-
pocket (MOOP). The MOOP amount for most 2016 Freedom Health
Plans is $3,400.
Maximum Out Of Pocket Expenses
36. H
Record Your Important Information
Plan Name:
PBP Number:
Enrollment Application Number:
Effective Date:
Network PCP Name & Number:
Over-the-Counter Allowance per month:
How to Enroll:
1. Have your Medicare ID or proof of eligibility ready before you begin the
application process.
2. You may complete the application on paper or through our website:
www.freedomhealth.com.
can help with any of these methods. If you need help, finding an agent,
call our toll-free number.
3. Medicare beneficiaries may also enroll in Freedom Health through
the CMS Medicare Online Enrollment Center located at
http://www.medicare.gov.
4. Choose a primary care physician. Use our Provider Directory to find
or go to our website at www.freedomhealth.com and from
the Quick Links section, choose Provider Search.
5. Look up your prescriptions in our formulary booklet or go to our
website and from the Quick Links section, choose the Drug Search.
36
37. More Supplies To Ch se From!
or call:1-866-900-2688 TTY: 711
You receive
medications
by mail
3
2We process
your order
1Visit our
website or
call to place
your order
37
Monthly Over-The-Counter Allowance - Benefits you can use everyday!
Log on to:
www.freedomhealth.com
38. 38
Save Time & Money in Over-the-Counter S
Item
6I Generic Comparable of Chloraseptic
6K Halls Sugar Free Cough Drops
6L Generic Comparable of Mucus Relief
6M Generic Comparable of Cepacol
(7)
7A Generic Comparable of Collyrium Eye Was
7B Generic Comparable of Visine
7C Generic Comparable of Visine Tears
7E Generic Comparable of Zaditor
(8) First Aid Creams
8A Generic Comparable of Benadryl Cream
8B Generic Comparable of Bacitracin
8C Generic Comparable of Lotrimin
8D Generic Comparable of Cortisone
8E Generic Comparable of Zinc Oxide
8F Generic Comparable of Neosporin
8G Generic Comparable of Micatin
8H Generic Comparable of Debrox
(9) Firs
9A Generic Comparable of Ace Bandage 3"
9B
9C Cotton Balls
9D Ice Bag
9E Generic Comparable of J&J Gauze
9F Digital Themometer
9G Generic Comparable of Q-Tips
(10
10A Generic Comparable of Colace
10B Generic Comparable of Fibercon
10C Generic Comparable of Miralax
10D Generic Comparable of Fleet Enema
(11) Misc
11A Digital Blood Pressure Kit*
11B Blood Pressure Kit*
11C Generic Comparable of Band Aid
11D Generic Comparable of Coppertone Sunscreen
11E Generic Comparable of Dramamine
Item Item Description Qty. Price
(1) Allergies
1A Generic Comparable of Chlortrimeton Chlorpheniramine Maleate 4mg 24 $4
1B Generic Comparable of Benadryl Elixir Diphenhydramine HCI 12.5 mg 118ml $3
1C Generic Comparable of Benadryl Caps Diphenhydramine HCI 25 mg 24 $3
1D Generic Comparable of Ocean Saline Nasal Spray Deep Sea Nasal Saline 0.65% 44ml $3
1E Nasacort Allergy 24 Hour 10.8 ml $15
1F Flonase Fluticasone propionate (glucocorticoid) 50mcg 9.9 ml $15
(2) Analgesics
2A Generic Comparable of Tylenol Ex 500mg 100 $4
2B Generic Comparable of Bayer Aspirin Aspirin 325mg 100 $3
2C Generic Comparable of Zostrix 60g $7
2E Generic Comparable of Advil 24 $3
2F Generic Comparable of Ben Gay Muscle Rub 35g $3
2G Generic Comparable of Aleve Naproxen sodium 220 mg CPL 50 $7
2H Generic Comparable of Bayer Aspirin Low Dose 81 mg Aspirin EC (Delayed Release) 81 mg 120 $4
2I Generic Comparable of Tylenol PM Acetaminophen 500 mg/Diphenhydramine HCI 25 mg 50 $5
2J Generic Comparable of Bayer Aspirin Low Dose Chewable Aspirin 81 mg Chewable 36 $4
2K Generic Comparable of Icy Hot Patch Cold and Hot Patch 5 $8
2L Generic Comparable of Excedrin Headache Formula-Aspirin/Acetaminophen/Caffeine 100 $7
(3) Antacids
3A Generic Comparable of Tums-Ex Calcium Carbonate 750 mg 96 $5
3B Generic Comparable of Gas-X 100 $5
3C Generic Comparable of Zantac 75 Ranitidine 75 mg 30 $9
3D Generic Comparable of Alka Seltzer Antacid & Pain Relief 12 $6
(4) Anti-Diarrheals
4A Generic Comparable of Imodium Loperamide 2 mg 12 $4
4B Generic Comparable of Pepto Bismol 30 $5
(5) Anti-Hemorrhoidals
5A Generic Comparable of Cortaid Maximum Strength Hydrocortisone oint, USP 1% 28g $6
5B Generic Comparable of Preparation H Prompt Relief Hem Ointment 57g $7
5C Generic Comparable of Preparation H Suppositories Hemorrhoidal Suppositories 12 $13
(6) Cough/Cold
6A Generic Comparable of Robitussin Sugar-free Dm Sugar-free cough syrup 118ml $5
6B Generic Comparable of Vicks Medicated Chest Rub 100g $6
6C Mucinex Dm Mucinex DM 600 mg 20 $20
6D Generic Comparable of Afrin nasal Spray Nasal Spray 15ml $3
6H Generic Comparable of Tylenol Sinus Congestion & Pain Sinus-Acetaminophen/Phenylephrine HCI 24 $5
*These items are considered dual purpose items. Prior to ordering these items, the enrollee must have an appropriate conversation with the enrollee’s p
DISCLAIMERS:
1. OTC items may only be purchased for the enrollee; it is prohibited to purchase supplies
for family members, and friends.
2. The following supplies are not covered as they are non-eligible supplies: Alternative
Medicines (Includes botanicals, herbals, probiotics, homeopathic, and neutraceuticals),
baby supplies, contraceptives, convenience & comfort supplies (insoles, gloves, etc.),
cosmetics, food products or supplements, replacement & attachments such as contact
lens containers or batteries.
3. To minimize mailing costs the plan may impose a limited ordering quantity per purchase.
4. This list is subject to change.
Orders will be shipped via UPS or USPS. Please allow 7-
receive your order from the time the order is placed.
6. Please consult with your doctor before using any OTC pro
7. All OTC supplies are generic comparable of Brand item. A
may be substituted for its Generic Comparable based on
8. All items are shipped based on manufacturer availability.
9. All items may not be available all the time.
10.If Generic Item is not acceptable, plan will not ship Brand
39. 39
Supplies. Choose From the Following List:
Item Description Qty. Price
Sore throat spray 177ml $5
Sugar Free Cough Drops 25 $4
Expectorant-Guaifenesin 400 mg 30 $7
Cepacol 16 $5
(7) Eye Care
e Wash Eye Wash 118ml $4
Redness Reliever Eye Drops 15ml $4
15ml $4
Eye-Itch Relief Antihistamine 5ml $15
eams & Ointments & Antiseptics
am Anti-Itch Cream 28g $3
Bacitracin 14g $6
Clotrimazole 1% Cream 28g $7
Hydrocortisone Cream 28g $5
Zinc Oxide Ointment 28g $8
1oz $6
Miconazole Nitrate 2% 28g $4
Ear wax removal .5oz $4
) First Aid Supplies
e 3" Elastic Bandage - 5 yards 1 $4
10 $2
Cotton Balls 100 $4
Ice Bag 9" 1 $9
Gauze Rolls - Assorted sizes 3 $4
1 $5
Cotton Swabs 300 $5
(10) Laxatives
Docusate sodium 100 mg 100 $5
Fiber-Lax 500 mg 60 $9
Clear Lax Powder 119g $11
Enema-Saline Laxative 133ml $3
Miscellaneous Items
Automatic Blood Pressure Kit 1 $29
1 $19
Adhesive Bandage 50 $3
screen Lotion Sunscreen Lotion SPF-30 113g $10
12 $4
Item Item Description Qty. Price
11F Pill Organizer 1 $7
11G DEX4 Glucose Tablets 50 $8
11H Pill Splitter Pill Splitter 1 $5
11I Eye Glass Wipes 1 box $4
11J Estroven Multi-Symptom Menopause Relief 30 $20
(12) Topical Foot & Topical Oral
12A Callus Remover Callus Removers 6 $4
12C Callus Cushion Callus Cushions 6 $3
12E Dental Flossers Dental Flossers 36 $3
12G Generic Comparable of Polident Denture Cleanser 40 $7
12H Toothpaste 2.7oz $4
12I Toothbrush 1 $3
12J Generic Comparable of Fixodent Denture Adhesives ADH CRM Fresh 1.4oz $5
(13) Vitamins & Minerals*
13A Fish Oil Fish Oil - 1200 mg. 90 $9
13B Prosight Supplement for eyes 60 $6
13C Allbee With C B Complex with C 100 $8
13D Vitamin B B Complex 100 $8
13E Vitamin C Vitamin C Chewable 500 mg. 100 $8
13F Generic Comparable of Centrum Multivitamin & Mineral 60 $6
13G Folic Acid Folic Acid 800 mcg 100 $5
13H Glucosamine Chondroitin Glucosamine Chondroitin 60 $15
13J Vitamin E Vitamin E 400 IU 100 $8
13K Vitamin D Vitamin D 1000 IU 100 $5
13L Antioxidant tablets 50 $7
13M Selenium Selenium 200 mcg 60 $7
13N Timed Release Niacin 60 $10
13O Generic Comparable of Lactaid Tab Lactase Enzyme Supplement 50 $9
13P Ferrous Sulfate Ferrous Sulfate - 325 mg 100 $3
13Q Generic Comparable of Citracal Calcium Citrate Calcium Citrate & Vitamin D 60 $7
13R Generic Comparable of Bayer One A Day Women’s One A Day Women's Multivitamin 60 $10
13S Generic Comparable of Os-Cal* Oyster Calcium + Vitamin D 100 $4
(14) Smoking Cessation
14B Generic Comparable of Nicorette 4mg 50 $24
(15) Sleep-Aids
15A Generic Comparable of Simply Sleep Sleep-tabs 25 mg 24 $4
15B Melatonin-Sleep Aid 60 $8
393939
Select from the items listed above and log on to:
or call: 1-866-900-2688, TTY: 711
Freedom Health is an HMO plan with a Medicare contract and a contract with the Florida Medicaid
program. Enrollment in Freedom Health, Inc. depends on contract renewal. This information is available
for free in other languages. Please call our Member Service Department at 1-800-401-2740 for additional
information. Hours are October 1 to February 14 from 8:00 am to 8:00 pm, 7 days a week and February
15 to September 30 from 8:00 am to 8:00 pm, Monday through Friday. TTY/TDD users should call 711.
Estainformaciónestádisponsiblegratuitamenteenotrosidiomas.Porfavor,llameanuestroDepartamento
de Servicios al Miembro al 1-800-401-2740 para información adicional. Los usuarios de TTY deben llamar
al 711. Nuestro horario es del 1ro de octubre hasta el 14 de febrero de 8 a.m. a 8 p.m., 7 días a la semana
y del 15 de febrero hasta el 30 de septiembre de 8 a.m. a 8 p.m. de lunes a viernes.
ee’s personal provider who
ow 7-10 business days to
TC products.
em. Any branded item
d on availability.
bility.
Brand Name Item.
40. SWe’re making it easier to find answers.
Try any of these four different ways:
1. Check the plan’s Evidence of Coverage
2. Visit a local Concierge Center
3. Go to www.freedomhealth.com
and search our website
4. Call Member Services
Still Have a Question?
Call Toll-Free: 1-800-401-2740
TTY: 711
8 am to 8 pm 7 days a week from October 1 to February 14
8 am to 8 pm Monday through Friday from February 15 - September 30.
We’re making it e
Try any of these
Check t
o find answers
different ways:
1. Check the plan’s Evidence of Co
2. Visit a local Concierge Center
3. Go to www.freedomh
and search our website
4. Call Member Service
Call Toll-Free: 1-8
TTY: 711
8 am to 8 pm 7 days a week from O
8 am to 8 pm Monday through Frid
40
43. To find out more details about
our plans, visit one of our concierge
centers listed on page 8, attend a
community event,(1)
or ask your
Freedom Health agent to stop by.
43
44. This information is available
for free in other languages.
Please call our customer
service number
Toll-Free at:
1-800-401-2740
TTY: 711
Hours:
8 am to 8 pm,
7 days a week from
October 1 to February 14
and
8 am to 8 pm,
Monday through Friday from
February 15th to September 30th.
www.freedomhealth.com
