2021 Medicare Passport ® Prime PPO

Plan Highlights

MONTHLY PREMIUM
PRIMARY/SPECIALTY COPAY
(In-Network)
INPATIENT HOSPITAL COPAY
(In-Network)
PART D PRESCRIPTION BENEFIT
(Tier 1 / 2 / 3 / 4 / 5)
MONTHLY PREMIUM

$215

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-6: $210 per day (IN) / 30% coinsurance (OON). Days 7-90: $0 (IN) / 30% coinsurance (OON). Unlimited Days for Medicare covered stays (IN). ($1,680 Annual Member Copay Maximum) (IN).

PART D PRESCRIPTION BENEFIT
(Tier 1 / 2 / 3 / 4 / 5)

In-Network and Out-Of-Network $0 deductible. $0/$10/$45/40%/33% to initial coverage limit of $4,130.

Plan Details

Monthly Premium

$215

Plan Premium with Full 100% Low Income Subsidy (LIS)

$172.70

Part D Prescription Benefit Tier 1 / 2 / 3 / 4 / 5

In-Network and Out-Of-Network $0 deductible. $0/$10/$45/40%/33% to initial coverage limit of $4,130.

Primary Copay

$0 (IN) / $45 (OON)

Specialty Copay

$30 (IN) / $45 (OON)

Inpatient Hospital Copay

Days 1-6: $210 per day (IN) / 30% coinsurance (OON). Days 7-90: $0 (IN) / 30% coinsurance (OON). Unlimited Days for Medicare covered stays (IN). ($1,680 Annual Member Copay Maximum) (IN).

Worldwide Emergency / Urgent Care*

$90 In-Network and Out-Of-Network / $65 In-Network and Out-Of-Network

Lab Copay**

$5 (IN) / 20% coinsurance (OON)

General X-ray / Advanced Radiology Copay

$30 (IN) / 20% coinsurance (OON) / $75 (IN) / 20% coinsurance (OON)

Premier Wellness Package***

Vision (from a network provider)

$0 (IN) / $65 (OON) for routine eye exam. $200 coverage limit for routine eyewear (IN) and (OON) combined. $0 for diabetic retinopathy exam for diabetics. $0 for Ophthalmologist too.

Dental (from a network provider)

$0 (IN) / $20 copay, then 50% coinsurance (OON) for preventive dental: Two routine cleanings, exams, fluoride treatments and bitewing X-rays per calendar year. One full-mouth series every 36 months. Comprehensive dental benefit built into plan: $0 deductible, 50% coinsurance (IN) / 50% reimbursement of what Independent Health would have paid a network provider (OON). $3,000 max annual limit.

SilverSneakers® Fitness Benefit (from a participating facility that offers SilverSneakers)

$0 copayment (memberships will not roll over from 2020 to 2021 or 2021 to 2022. Memberships will restart on January 1st of each year).

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam (IN). Member pays: $499 or $2,799 (per ear) for hearing aid devices (IN). $75 hearing aid evaluation (OON). The cost for hearing aids without coverage is $2,445 or $3,125 per ear.

Enhanced Annual Wellness Visit (EAV)

$0 (IN)

Telemedicine (from a network provider)

$25 copay per session (IN) / 100% coinsurance (OON). Speak with a doctor anytime, anywhere by phone or online.

All of our Medicare Advantage plans come with additional benefits to help you maintain an active, healthy lifestyle.

Disclaimers

* $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 or Independent Health’s Medicare Passport Prime PPO plan). Must see an American Hearing Benefits network provider to use the hearing aid benefit.

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. Call (716) 250-4401 or 1-800-665-1502 (TTY users call 711) for more information.

Out-of-network/non-contracted providers are under no obligation to treat Independent Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

IN = In-Network, OON = Out-of-Network

Y0042_C7173
Last Updated 10/01/2021