Independent Health's
Passport® Advantage PPO plan
This plan may be right for you if you want a plan that offers you the flexibility to see any doctor who accepts Medicare, wherever you are.

Plan Highlights

Monthly Premium
$128
Primary/Specialty Copay
(In-Network)
$20 / $35
Inpatient Hospital Copay
(In-Network)
Days 1-7: $250 per day
Days 8-90: $0
Part D Prescription Benefit
Tier 1 / 2 / 3 / 4 / 5
No deductible
$4 / $12 / $45 / 45% / 33%
to initial coverage limit of $3,700

Plan Details

Reference your Annual Notice of Change/Evidence of Coverage for full benefit information. (IN) In-Network. (OON) Out of Network.
Monthly Plan Premium $128
Premium w/ EPIC or Full LIS $87
Medical Deductible $500
Enhanced Annual Wellness Visit* $0
Vision* $20 routine eye exam (IN)
$150 allowance for routine eyewear
(IN) (OON)
Preventive Dental*
(from a network provider)
$20 copay: Two routine cleanings, exams & bitewing X-rays per calendar year. One full-mouth series every 36 months.
Gym Membership* Healthy Benefits Gym Membership for one calendar year. ($30 activation fee)
Hearing Aid Benefit* $45 hearing aid evaluation exam Member pays: $699 or $999 (per ear/per year) for hearing aid device. The average cost for hearing aids without coverage is $1,850 or $2,995 per ear.
Primary Copay $20 (IN) / $40 (OON)
Specialty Copay $35 (IN) / $40 (OON)
Inpatient Hospital Copay Days 1-7: $250 copay per day (IN)
Days 8 – 90: $0 per day (IN)
Deductible and 30% coinsurance (OON)
Worldwide Emergency and Urgent Care $75 / $65
Lab Copay** Deductible and $0 (IN)
Deductible and 30% coinsurance (OON)
Outpatient Surgery Deductible and $250 Copay (IN)
Skilled Nursing Facility*** Days 1–20: Deductible and $0 per day
Days 21–100: $75 copay per day (IN)
Home Health Deductible and $0 (IN)
Physical, Speech, Occupational Therapy Deductible and $15 copay (IN)
% You Pay for Part B Medications or Radiation Therapy Deductible and 20% coinsurance (IN)
Annual Out-of-Pocket Maximum for Medicare Covered Services $6,700 (IN)
X-ray Copay General X-Ray: Deductible and $35 copay (IN)
Deductible and 50% coinsurance (OON)
Advanced Radiology: Deductible and $75 copay (IN)
Deductible and 50% coinsurance (OON)
Part D Prescription Benefit
Tier 1 / 2 / 3 / 4 / 5
No deductible
$4 / $12 / $45 / 45% / 33% to initial coverage limit of $3,700.
Additional Plan Benefits - All of our Medicare Advantage plans come with additional benefits to help you maintain an active, healthy lifestyle.
 

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Disclaimers
Independent Health is a Medicare Advantage organization with a Medicare contract offering HMO, HMO-SNP, HMO-POS, and PPO plans. Enrollment in Independent Health depends on contract renewal. Limitations, copayments, and restrictions may apply. Benefit, premium and/or copayments/coinsurance 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. Benefits vary by plan. Restrictions apply. Members may enroll in the plan only during specific times of the year. Contact Independent Health for more information. This plan is available to all Medicare eligibles that are entitled to Medicare Part A and enrolled in Part B, except those with ESRD unless already enrolled with Independent Health. You must continue to pay your Medicare Part B premium.

*Applicable copays may apply for these benefits. This is the maximum benefit value that a member could receive if they used all of these benefits. Maximum benefit value will vary by plan and depends on which services the member uses. Member must use EyeMed, HealthPlex or TruHearing providers in order to take advantage of these benefits.
Our hearing aid coverage includes a $45 copayment for a hearing exam through TruHearing. Up to two TruHearing Flyte hearing aids every year (one per ear, per year). Benefit is limited to the TruHearing Flyte 700 ($699 per ear, per year) and Flyte 900 ($999 per ear, per year) hearing aids, which come in various styles and colors. You must see a TruHearing provider to use this benefit. To schedule an appointment, call 1-844-211-1723 toll-free (TTY users call 1-800-975-2674). Routine hearing exam/fitting and hearing aid copayments are not subject to the out-of-pocket maximum. This is not a complete description of benefits. See your Evidence of Coverage for full details.
**Member pays 20% for genetic testing.
***Skilled nursing facility benefit is not covered after day 100, per benefit period. Benefit covers rehabilitation services only.
†Member pays 20%–30% of the cost of the Part B medication (e.g., injectables and chemotherapy) or radiation therapy service plus applicable office visit copay or the outpatient hospital copay.
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Y0042_C5900 Approved 11052017
Last Updated 11/8/2017