2022 Medicare Passport® Advantage 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

$99

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$35

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-6: $275 per day (IN) / 40% coinsurance (OON). Additional days: $0 (IN) / 40% coinsurance (OON). Unlimited days for Medicare covered stays (IN). ($1,925 Annual Member Copay Maximum) (IN).

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

In-Network and Out-Of-Network. $150 deductible on tiers 3, 4 & 5 only. $0/$15/$47/40%/30% to initial coverage limit of $4,430.

Plan Details

Monthly Premium

$99

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

$56.60

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

In-Network and Out-Of-Network $150 deductible on tiers 3, 4 & 5 only. $0/$15/$47/40%/30% to initial coverage limit of $4,430.

Primary Copay

$0 (IN) / 40% coinsurance (OON)

Specialty Copay

$35 (IN) / 40% coinsurance (OON)

Inpatient Hospital Copay

Days 1-6: $275 per day (IN) / 40% coinsurance (OON). Additional days: $0 (IN) / 40% coinsurance (OON). Unlimited days for Medicare covered stays (IN). ($1,925 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**

$0 (IN) / 40% coinsurance (OON)

General X-ray / Advanced Radiology Copay

$40 (IN) / 40% coinsurance (OON) / $150 (IN) / 40% coinsurance (OON)

NEW! Over-the-Counter***

$25 per quarter

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 (IN) for diabetic retinopathy exam for diabetics. $0 (IN) for Ophthalmologist too.

Dental (from a network provider)

$20 (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. Optional supplemental dental: 1 option offered for additional $25 premium billed separately. $750 every 3 months - Jan, April, July, Oct. $3,000 max limit, $0 deductible, 50% coinsurance.

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

$0 copayment (memberships will not roll over from 2021 to 2022 or 2022 to 2023. 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 - $2,799 (per ear) for hearing aid devices (IN). 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. Click here for details.

Disclaimers

* $10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.

** Member pays 20% (IN) or 40% (OON) of the cost of genetic testing.

***Allowance is made available by quarter. Allowance does not carry over quarter to quarter or plan year to plan year. Costs over the allowed amount are the member’s responsibility. This benefit can only be used for covered items through NationsOTC.®

† 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 a Start Hearing 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