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2026 Medicare Passport ® Connect 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

$58.80

PRIMARY/SPECIALTY COPAY
(In-Network)

Tier A: $0/$55

Tier B: $20/$55

INPATIENT HOSPITAL COPAY
(In-Network)

Tier A: Days 1-6: $375 per day (IN) / deductible then 50% coinsurance (OON). Days 7-90: $0 (IN) / deductible then 50% coinsurance (OON). Unlimited Days for Medicare covered stays (IN). ($2,250 Annual Member Copay Maximum) (IN).

Tier B: Days 1-4: $550 per day (IN) / deductible then 50% coinsurance (OON). Days 5-90: $0 (IN) / deductible then 50% coinsurance (OON). Unlimited Days for Medicare covered stays (IN). ($2,445 Annual Member Copay Maximum) (IN)

PART D PRESCRIPTION BENEFIT

In-Network and Out-Of-Network. $615 deductible on all tiers. 25%/25%/25%/25%/25% to out-of-pocket maximum of $2,100.

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Does this plan fit for you? Take the next step and enroll today!

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Plan Details

Monthly Premium

$58.80

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

$0

Annual Medical Deductible (on certain services)

$175

Part D Prescription Benefit Tier 1 / 2 / 3 / 4 / 5 (uses Standard formulary)

In-network: $615 deductible on all tiers. 25%/25%/25%/25%/25% to out-of-pocket maximum of $2,100.

Primary Copay

Tier A: $0, Tier B: $20 (IN) / Deductible then 50% (OON)

Specialty Copay

$55 (IN) / Deductible then 50% (OON)

Preventive Services

$0 (IN) / 50% coinsurance (OON)

Inpatient Hospital Copay

Tier A: Days 1-6: $375 per day, Tier B: Days 1-4: $550 per day (IN) / Deductible then 50% coinsurance (OON). TIer A: Days 7-90: $0, Tier B: Days 5-90: $0 (IN) / Deductible then 50% coinsurance (OON). Unlimited Days for Medicare covered stays (IN). (Annual Member Copay Maximum Tier A: $2,250, Tier B: $2,445) (IN).

Outpatient Mental Health Care

$35 (IN) / Deductible then 50% (OON)

Worldwide Emergency / Urgent Care*

$115 In-Network and Out-Of-Network / $40 In-Network and Out-Of-Network

Ambulance

Ground: $265 In-Network, Deductible then $265 Out-of-Network

Lab Copay**

$0 (IN) / Deductible then 50% coinsurance (OON)

General X-ray / Advanced Radiology Copay

General X-ray: $45 (IN) / Deductible then 50% coinsurance (OON)

Advanced Radiology: Tier A: $225, Tier B: $550 (IN) / Deductible then 50% coinsurance (OON)

Outpatient Surgery

Ambulatory Surgical Center: $375 (IN) / Deductible then 50% (OON)

Hospital-based: Deductible then Tier A: $425, Tier B: $550 (IN) / Deductible then 50% (OON)

Skilled Nursing Facility

Days 1 - 20: $0 (IN) / Deductible then 50% (OON)

Days 21 - 100: $218 per day (IN) / Deductible then 50% (OON)

Home Health

$0 (IN) / Deductible then 50% (OON)

Physical, Speech and Occupational Therapy

$30 (IN) / Deductible then 50% (OON)

Part B Medications

0% - 20% (IN) / Deductible then 50% (OON)

Annual Out-of-Pocket Maximum for Medicare Covered Services

$9,250 (IN) / $13,900 combined (IN) (OON)

Wellness Benefits†

Dental

$1,500 combined maximum for preventive dental and comprehensive dental (IN & OON).

Preventive Dental: $0 copay for preventive dental with a Liberty Dental provider. Two routine cleanings, exams, fluoride treatments and bitewing X-rays per calendar year. One full-mouth series every 36 months. (IN)

Comprehensive Dental: 50% coinsurance with a Liberty Dental provider (IN).

 

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

$0 copayment (Memberships will not roll over from 2025 to 2026 or 2026 to 2027. Memberships will restart on January 1st of each year.)

Vision

$0 (IN) / $65 (OON) for routine eye exam. $200 annual allowance for routine eyewear (IN & OON).

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam (IN). $250 hearing aid allowance per ear. Member pays: $499 - $1,949 price per hearing aid (IN). The cost for hearing aids without coverage is $2,445 - $3,125 per ear.

Telemedicine (with a Teladoc® provider)

$25 copay per session (IN). Speak with a doctor anytime, anywhere by phone or online.  Behavioral Health is covered at $0 copay (IN).

Chiropractic Evaluation & Management

$15 chiropractic coverage (IN) / Deductible then 50% for Medicare covered chiropractic, 50% coinsurance for evaluation and management (OON)

Additional Wellness Benefits

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

Disclaimers

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

* $10,000 maximum per occurrence for emergency care, urgent care or ambulance outside the USA and its territories.

** Member pays 20% (IN) or Deductible then 50% (OON) 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 Connect 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.

Y0042_C7173
Last Updated 10/1/2025

© Independent Health Association, Inc.

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