Independent Health's
Medicare Passport® Advantage PPO
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Here is an outline of some of the specific changes in your current plan for 2018.

Please note: There is a special network with this PPO plan in 2018. Speak with a RedShirt today for more information.

You can also review your Annual Notice of Change / Evidence of Coverage for a complete list of plan changes and 2018 benefits:
2017 2018
Monthly Premium $128 $87
Plan Premium with assistance from EPIC or FULL LIS $87 $48
Medical Deductible $500 No medical deductible
Part D Prescription Benefit Tier 1/2/3/4/5 No deductible
$4 /$12 / $45 / 45% / 33% to initial coverage limit of $3,700
No deductible
$0 / $20 / $47 / 50% / 33% to initial coverage limit of $3,750
Primary Copay $20 (IN) / $40 (OON) $0 (IN) / $25 (OON)
Specialty Copay $35 (IN) / $40 (OON) $45 (IN) / $75 (OON)
Inpatient Hospital Copay Days 1-7: $250 copay per day (IN) Deductible and 30% coinsurance (OON) Days 1-7: $250 per day (IN)
Days 8-90: $0 per day (IN) / 40% coinsurance (OON)
Worldwide Emergency and Urgent Care* $75 (IN) and (OON) / $65 (IN) and (OON) $80 (IN) and (OON) / $65 (IN) and (OON)
Lab Copay** Deductible and $0 (IN)
Deductible and 30% coinsurance (OON)
$0 (IN)
40% coinsurance (OON)
General X-ray / Advanced Radiology Copay General X-Ray: Deductible and $35 copay (IN). Advanced Radiology: Deductible and $75 copay (IN). Deductible and 50% coinsurance (OON) General X-Ray: $35 / Advanced Radiology: $150 copay (IN) / 40% coinsurance (OON)
PASSPORT PREMIER WELLNESS PACKAGE***:
Vision
(from a network provider)
$20 routine eye exam
$150 coverage limit for routine eyewear (IN) and (OON) combined.
$0 routine eye exam
$200 coverage limit for routine eyewear (IN) and (OON) combined.
Preventive Dental
(from a network provider)†
$20 per visit preventive dental: Two routine cleanings, exams and bitewing X-rays per calendar year. One full-mouth series every 36 months. (IN) $0 preventive dental: Two routine cleanings, exams and bitewing X-rays per calendar year.
One full-mouth series every 36 months. (IN)
Gym Membership
(from a network provider)
Healthy Benefits Gym Membership for one calendar year. ($30 activation fee) (IN) Healthy Benefits Gym Membership for one calendar year. ( $20 activation fee) (IN)
Hearing Aid Benefit
(from a network provider)†
$45 hearing aid evaluation exam. Member pays $699 or $999 (per ear/per year) for hearing aid devices. The cost of these hearing aids without coverage is $1,850 or $2,995 per ear. (IN) $45 hearing aid evaluation exam. Member pays: $599 or $899 (per ear) for hearing aid devices. The cost for hearing aids without coverage is $1,850 or $2,995 per ear. (IN)
Enhanced Annual Wellness Visit (EAV)† $0 (IN) $0 (IN)
New! Telemedicine
(from a network provider)
Not offered. $25 copay per session. Speak with a doctor anytime, anywhere by phone or online. (IN)
FitWorks Medicare Earn a $50 TOPS gift card for living healthy. See your doctor, get screenings, get active-get rewarded! Earn a $50 TOPS gift card for living healthy. See your doctor, get screenings, get active-get rewarded!

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.
*$10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.
**Member pays 20% of the cost of genetic testing.
***Limitations, copayments and restrictions may apply. Applicable copays may apply for these benefits. Member must use in-network providers to take advantage of these benefits (excluding Independent Health’s Medicare Passport Advantage PPO plan). Must see a TruHearing provider to use the hearing aid benefit.
†Excludes Independent Health’s Medicare Family Choice HMO-SNP. Benefits vary by plan and some plans do not include coverage for these benefits. Benefits premiums, rewards and/or copayments may change on January 1 of each year. This information is not a complete description of benefits. Contact the plan for more information. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. This chart is for general reference and is not a contract. See Evidence of Coverage for complete details. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
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Y0042_C5900 Approved 11052017
Last Updated 11/8/2017