Mutual
of Omaha
| Plan Name | Freedom 1 | Freedom 2 | Freedom 5 | |
|
Plan Number
|
H0846-004 | H0846-005 | H5227-001 | |
| Monthly Premium | $98 | $0 | $32 | |
| Deductible | $0 | $0 | $0 | |
| Doctor visit |
|
|||
|
Primary Physician
|
$0 copay | $15 copay | $15 copay |
|
|
Specialist
|
$0 copay | $30 copay | $30 copay |
|
|
Podiatrist
|
$0 copay | $30 copay | $30 copay |
|
| Diagnostic Tests & X-Rays | $0 copay | $15-50 copay | $15-50 copay | |
| Laboratory Services | $0 copay | $5 copay | $5 copay | |
| Inpatient Hospitalization | days 1 - unlimited: $0/day |
days
1 -
5:
$180/day
days 6 - unlimited: $0/day |
days
1 -
5:
$180/day
days 6 - unlimited: $0/day |
|
| Outpatient Surgery | $0 copay | $90 copay | $90 copay | |
| Emergency Room Visit | $50 copay | $50 copay | $50 copay | |
| Urgent Care Visit | $0 copay | $50 copay | $50 copay | |
| Ambulance Services | $150 copay | $150 copay | $150 copay |
|
| Preventive Care |
|
|||
|
Annual Physical Exam
|
$0 | $0 | $0 | |
|
Immunizations
|
$0 | $0 | $0 | |
|
GYN Exams
|
$0 | $0 | $0 | |
|
Screening Mammograms
|
$0 | $0 | $0 | |
|
Colorectal Screening Exams
|
$0 | $0 | $0 | |
|
Prostate Exam
|
$0 | $0 | $0 | |
| Routine Vision & Hearing | ||||
|
Annual Exams
|
$20 copay | $30 copay | $30 copay | |
|
Eyeglass Benefit
|
$100 / year | $100 / year | $100 / year | |
|
Hearing Aid Benefit
|
$100 / year | $100 / year | $100 / year | |
| Preventive Dental |
|
|||
|
Cleanings & Checkups
|
50% coinsurance | 50% coinsurance | 50% coinsurance | |
|
X-Rays
|
50% coinsurance | 50% coinsurance | 50% coinsurance | |
| Out-of-Pocket Maximum | $1000 | $3000 | $3250 | |
| Prescription Drug Coverage | Select any Part D plan | Select any Part D plan | Part D prescription benefits | |
| Summary of Benefits | click to view PDF | click to view PDF | click to view PDF | |
| Evidence of Coverage | Coming Soon | Coming Soon | Coming Soon | |
| Enroll online | Enroll online | Enroll online | ||
Advantra Freedom is offered through Coventry Health and Life Insurance Company, Cambridge Insurance Company and First Health Life & Health Insurance Company, subsidiaries of Coventry Health Care, Inc., who contract with CMS. Contracts are renewed annually and the availability of coverage beyond the contract year is not guaranteed.
You must continue to pay your Medicare Part B premium.
A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital must agree to accept the plan's terms and conditions prior to providing healthcare services to you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies. Providers can find the plan's terms and conditions on our website by clicking here.
For more
information
on Advantra
Freedom’s
benefits,
call
Customer
Service at:
1 (800) 711-1607; (TDD) 1 (888) 788-4010 Monday through Friday from 8:00 a.m. - 11:00 p.m., Eastern Standard Time. From November 15-March 15, additional Saturday and Sunday hours 8:00 a.m - 11:00 p.m. Eastern Standard time.
