Independent Health's
Medicare Passport® Advantage PPO
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If you’re happy in your current plan you don’t have to do anything and you will be automatically re-enrolled for 2017.
If you have questions or would like to change your plan, you can get the answers you need with help from a RedShirt.

Here is an outline of some of the specific changes in your current plan for 2017.

View the following documents for a complete list of plan changes and 2017 plan benefits:
2016 2017
Monthly Premium $125 $128
Premium w/ EPIC or Full LIS $85.30 $87
Medical Deductible $600 $500
Enhanced Annual Wellness Visit* $0 $0
Vision* $0 routine eye exam (IN)
$150 allowance for routine eyewear
(IN)
$20 routine eye exam (IN)
$150 allowance for routine eyewear
(IN)
Preventive Dental (from a network provider)* $0 copay: Two routine cleanings, exams & bitewing X-rays per calendar year. One full-mouth series every 36 months.
(IN) & (OON)
$20 copay: Two routine cleanings, exams & bitewing X-rays per calendar year. One full-mouth series every 36 months.
(IN) & (OON)
Gym Membership* Healthy Benefits Gym Membership for one calendar year. ($20 activation fee)
(IN)
Healthy Benefits Gym Membership for one calendar year. ($30 activation fee)
(IN)
Hearing Aid Benefit* Not offered. $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) $20 (IN) / $40 (OON)
Specialty Copay $35 (IN) / $40 (OON) $35 (IN) / $40 (OON)
Inpatient Hospital Copay Days 1-7: $250 copay per day
$0 per day, days 7-90 (IN)
Deductible and 30% coinsurance (OON)
Days 1-7: $250 copay per day
$0 per day, days 7-90 (IN)
Deductible and 30% coinsurance (OON)
Worldwide Emergency and Urgent Care $75 / $65 $75 / $65
Lab Copay** $0 (IN)
Deductible and 30% coinsurance (OON)
$0 (IN)
Deductible and 30% coinsurance (OON)
General X-ray General X-Ray: Deductible and $35 copay (IN)
Advanced Radiology: Deductible and $75 copay (IN)
Deductible and 30% coinsurance (OON)
General X-Ray: Deductible and $35 copay (IN)
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 / $90 / 33% to initial coverage limit of $3,310
No deductible
$4 / $12 / $45 / 45% / 33% to initial coverage limit of $3,700

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.
*Applicable copays may apply for these benefits. Member must use EyeMed, HealthPlex or TruHearing providers in order to take advantage of these benefits. Refer to the Evidence of Coverage for complete details. Our Enhanced Annual Wellness Visit, Dental and Hearing aid benefits are not included with Independent Health’s Medicare Family Choice HMO- SNP. **Member pays 20% for genetic testing. Benefits vary by plan. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments may change on January 1 of each year. The provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium.
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Y0042_C5683 Approved
Last Updated: 11/17/2016