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2024 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

$235

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-7: $225 per day (IN) / 30% coinsurance (OON). Days 7-90: $0 (IN) / 30% coinsurance (OON). Unlimited Days for Medicare covered stays (IN). ($1,575 Annual Member Copay Maximum) (IN).

PART D PRESCRIPTION BENEFIT

In-Network and Out-Of-Network. $0 deductible. $0/$10/$45/50%/33% to initial coverage limit of $5,030.

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

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Plan Details - note: this plan will not be offered effective 1/1/2025

Monthly Premium

$235

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

$186.30

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

In-Network and Out-Of-Network $0 deductible. $0/$10/$45/50%/33% to initial coverage limit of $5,030.

Primary Copay

$0 (IN) / $45 (OON)

Specialty Copay

$30 (IN) / $45 (OON)

Preventive Services

$0 (IN) / 20% coinsurance (OON)

Inpatient Hospital Copay

Days 1-7: $225 per day (IN) / 30% coinsurance (OON). Days 7-90: $0 (IN) / 30% coinsurance (OON). Unlimited Days for Medicare covered stays (IN). ($1,575 Annual Member Copay Maximum) (IN).

Outpatient Mental Health Care

$20 (IN) / 40% (OON)

Worldwide Emergency / Urgent Care*

$100 In-Network and Out-Of-Network / $55 In-Network and Out-Of-Network

Ambulance

$200 In-Network and Out-Of-Network

Lab Copay**

$0 (IN) / 20% coinsurance (OON)

General X-ray / Advanced Radiology Copay

General X-ray: $30 (IN) / 20% coinsurance (OON) 

Advanced Radiology: $100 (IN) / 20% coinsurance (OON)

Outpatient Surgery

Ambulatory Surgical Center: $265 (IN) / 20% (OON)

Hospital-based: $315 (IN) / 20% (OON)

Skilled Nursing Facility

Days 1 - 20: $0 (IN) / 30% (OON)

Days: 21 - 100: $203 per day (IN) / 30% (OON)

Home Health

$0 (IN) / 40% (OON)

Physical, Speech and Occupational Therapy

$10 (IN) / 20% (OON)

Part B Medications or Radiation Therapy

Part B Medications: 0% - 20% (IN) / 40% (OON)

Radiation Therapy: 20% (IN) / 40% (OON)

Annual Out-of-Pocket Maximum for Medicare Covered Services

$7,300 (IN) / $12,500 combined (IN) (OON)

RedShirt Rewards

Earn up to $100 in RedShirt Rewards for taking healthy actions!
Learn More

Wellness Benefits†

Dental

$1,000 combined maximum for preventive dental and comprehensive dental (IN & OON).

Preventive Dental: $0 copay (IN) 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: $0 deductible, 50% coinsurance (IN).

Coverage up to the in-network contractual payment amount for out-of-network services.

Over-the-Counter (OTC)***

$25 per quarter

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

$0 copayment (Memberships will not roll over from 2023 to 2024 or 2024 to 2025. Memberships will restart on January 1st of each year.)

Vision

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

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam (IN). Member pays: $499 - $2,199 (per ear) for hearing aid devices (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.

Enhanced Diabetes Benefits

These benefits will help members with diabetes manage their special needs, live healthier and save money. Learn More

Chiropractic Evaluation & Management

$15 Medicare Chiropractic coverage (IN) / 40% (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 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.

***Allowance is made available by quarter. Allowance carries over quarter to quarter, however does not carry over 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.

 

Y0042_C7173
Last Updated 10/1/2024

© Independent Health Association, Inc.

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