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Description of the ADVANTAGE Preferred Plus (PPO) plan (H5508 - 002) in St. Joseph, Indiana



Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the ADVANTAGE Preferred Plus (PPO) plan (H5508 - 002) in St. Joseph, Indiana only.   To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see this information for the ADVANTAGE Preferred Plus (PPO) plan in a chart format along with the plan enrollment options. We will also send a copy of the plan benefit details chart to your email account.

Plan Premium
The ADVANTAGE Preferred Plus (PPO) plan has a monthly premium of $34.00. That is $408.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $34.00 montly premium is in addition to your Medicare Part B premium.

This Medicare Advantage Plan without Prescription Drug Coverage is a Local PPO * plan. This plan has a Maximum Out-of-Pocket (MOOP) Limit for Medicare Part A & Medicare Part B expenses of $3,400.

Plan Membership and Plan Ratings
The ADVANTAGE Preferred Plus (PPO) plan currently has 369 members in St. Joseph county. and The Centers for Medicare and Medicaid Services (CMS) has rated the plan carrier as follows: a Customer Service Rating of 4 out of 5 stars a Member Experience Rating of 4 out of 5 stars a Drug Cost Information Accuracy Rating of 4 out of 5 stars.

Please be aware that this plan does NOT include Prescription Drug Coverage!
The ADVANTAGE Preferred Plus (PPO) plan offers many Health Coverage Benefits. The following section will describe these benefits in detail.
Cost - Premium and Other Important Information
$34.00 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
This plan covers all Medicare-covered preventive services with zero cost sharing.
$3 400 out-of-pocket limit.
This limit includes only Medicare-covered services.
$5 100 out-of-pocket limit.
In-Network: This limit includes only Medicare-covered services.
Out-Of-Network: This limit includes only Medicare-covered services.
Doctor and Hospital Choice - Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
Extra Benefits - Prescription Drugs
Most drugs not covered.
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
20% of the cost for Part B drugs out-of-network.
This plan does not offer prescription drug coverage.
Extra Benefits - Physical Exams
$0 copay for routine exams.
Limited to 1 exam(s) every year.
$0 copay for routine exams.
Extra Benefits - Vision Services
$0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery
  • glasses
  • contacts
  • $0 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $20 copay for up to 1 routine eye exam(s) every year
  • $100 plan coverage limit for eye wear every two years.
    20% of the cost for eye exams.
    20% of the cost for eye wear.
    Extra Benefits - Dental Services
    $0 copay for Medicare-covered dental benefits.
    $10 copay for an office visit that includes:
  • up to 1 oral exam(s) every six months
  • up to 1 cleaning(s) every six months
  • up to 1 fluoride treatment(s) every six months
  • up to 1 dental x-ray(s) every year
  • $10 copay for preventive dental benefits.
    20% of the cost for comprehensive dental benefits.
    $200 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    Important Information - Premium and Other Important Information
    $34.00 monthly plan premium in addition to your monthly Medicare Part B premium.
    Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
    This plan covers all Medicare-covered preventive services with zero cost sharing.
    $3 400 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    $5 100 out-of-pocket limit.
    In-Network: This limit includes only Medicare-covered services.
    Out-Of-Network: This limit includes only Medicare-covered services.
    Important Information - Doctor and Hospital Choice
    No referral required for network doctors specialists and hospitals.
    You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
    Inpatient Care - Inpatient Hospital Care (Acute)
    No limit to the number of days covered by the plan each benefit period.
    For Medicare-covered hospital stays:
    Days 1 - 5: $125 copay per day
    Days 6 - 90: $0 copay per day
    $0 copay for additional hospital days
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Inpatient Care - Inpatient Mental Health Care
    You get up to 190 days in a Psychiatric Hospital in a lifetime.
    For Medicare-covered hospital stays:
    Days 1 - 5: $125 copay per day
    Days 6 - 90: $0 copay per day
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Same deductible and copay as inpatient hospital care (see 'Inpatient Hospital Care')
    Inpatient Care - Skilled Nursing Facility (SNF)
    Authorization rules may apply.
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For SNF stays:
    Days 1 - 20: $0 copay per day
    Days 21 - 100: $75 copay per day
    Inpatient Care - Home Health Care
    Authorization rules may apply.
    $0 copay for Medicare-covered home health visits.
    $0 copay for home health visits.
    Inpatient Care - Hospice
    You must get care from a Medicare-certified hospice.
    Outpatient Care - Doctor Office Visits
    See 'Welcome to Medicare; and Annual Wellness Visit' for more information.
    $10 copay for each primary care doctor visit for Medicare-covered benefits.
    $50 copay for each in-area network urgent care Medicare-covered visit.
    $30 copay for each specialist visit for Medicare-covered benefits.
    20% for each primary care doctor visit.
    20% for each specialist visit.
    Outpatient Care - Chiropractic Services
    $25 copay for each Medicare-covered visit.
    Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
    20% of the cost for chiropractic benefits.
    Outpatient Care - Podiatry Services
    $25 copay for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    20% of the cost for podiatry benefits.
    Outpatient Care - Outpatient Mental Health Care
    Authorization rules may apply.
    $25 copay for each Medicare-covered individual or group therapy visit.
    45% of the cost for Mental Health benefits.
    20% of the cost for Mental Health benefits with a psychiatrist.
    Outpatient Care - Outpatient Substance Abuse Care
    Authorization rules may apply.
    $25 copay for Medicare-covered individual or group visits.
    20% of the cost for outpatient substance abuse benefits.
    Outpatient Care - Outpatient Hospital Services
    Authorization rules may apply.
    $150 copay for each Medicare-covered ambulatory surgical center visit.
    $150 copay for each Medicare-covered outpatient hospital facility visit.
    20% of the cost for ambulatory surgical center benefits.
    20% of the cost for outpatient hospital facility benefits.
    Outpatient Care - Emergency Care
    $50 copay for Medicare-covered emergency room visits.
    Worldwide coverage.
    If you are admitted to the hospital within 72-hour(s) for the same condition you pay $0 for the emergency room visit
    Outpatient Care - Outpatient Rehabilitation Services
    Authorization rules may apply.
    There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits.
    $25 copay for Medicare-covered Occupational Therapy visits.
    $25 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
    $0 copay for Medicare-covered Cardiac Rehab services.
    20% of the cost for Occupational Therapy benefits.
    20% of the cost for Physical and/or Speech and Language Therapy visits.
    20% of the cost for Cardiac Rehab services.
    Outpatient Medical Services and Supplies - Durable Medical Equipment
    Authorization rules may apply.
    20% of the cost for Medicare-covered items.
    20% of the cost for durable medical equipment.
    Outpatient Medical Services and Supplies - Prosthetic Devices
    Authorization rules may apply.
    20% of the cost for Medicare-covered items.
    20% of the cost for prosthetic devices.
    Outpatient Medical Services and Supplies - Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    20% of the cost for Diabetes supplies.
    20% of the cost for Diabetes self-monitoring training.
    20% of the cost for Nutrition Therapy for Diabetes.
    20% of the cost for Diabetes supplies.
    Preventive Services - Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement
    $0 copay for Medicare-covered bone mass measurement.
    Preventive Services - Colorectal Screening Exams
    Authorization rules may apply.
    $0 copay for Medicare-covered colorectal screenings.
    $0 copay for colorectal screenings.
    Preventive Services - Immunizations
    $0 copay for Flu and Pneumonia vaccines.
    $0 copay for Hepatitis B vaccine.
    No referral needed for Flu and pneumonia vaccines.
    $0 copay for immunizations.
    Preventive Services - Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams.
    $0 copay for pap smears and pelvic exams.
    Preventive Services - Prostate Cancer Screening Exams
    $0 copay for
    • Medicare-covered prostate cancer screening
    $0 copay for prostate cancer screening.
    Additional Benefits - Dialysis
    Authorization rules may apply.
    $0 copay for renal dialysis
    $0 copay for Nutrition Therapy for End-Stage Renal Disease
    20% of the cost for renal dialysis.
    20% of the cost for Nutrition Therapy for End-Stage Renal Disease.
    Additional Benefits - Prescription Drugs
    Most drugs not covered.
    20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
    20% of the cost for Part B drugs out-of-network.
    This plan does not offer prescription drug coverage.
    Additional Benefits - Dental Services
    $0 copay for Medicare-covered dental benefits.
    $10 copay for an office visit that includes:
  • up to 1 oral exam(s) every six months
  • up to 1 cleaning(s) every six months
  • up to 1 fluoride treatment(s) every six months
  • up to 1 dental x-ray(s) every year
  • $10 copay for preventive dental benefits.
    20% of the cost for comprehensive dental benefits.
    $200 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    Additional Benefits - Hearing Services
    In general routine hearing exams and hearing aids not covered.
    $0 copay for Medicare-covered diagnostic hearing exams
    20% of the cost for hearing exams.
    Additional Benefits - Vision Services
    $0 copay for
    • one pair of eyeglasses or contact lenses after cataract surgery
  • glasses
  • contacts
  • $0 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $20 copay for up to 1 routine eye exam(s) every year
  • $100 plan coverage limit for eye wear every two years.
    20% of the cost for eye exams.
    20% of the cost for eye wear.
    Additional Benefits - Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s) every year.
    $0 copay for routine exams.
    Additional Benefits - Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Written health education materials including Newsletters
  • Additional Smoking Cessation
  • Nursing Hotline
  • Other Wellness Benefits
  • $0 copay for each Medicare-covered smoking cessation counseling session.
    $0 copay for each Medicare-covered HIV screening.
    HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.
    $0 copay for Health and Wellness services.
    Additional Benefits - Transportation
    This plan does not cover routine transportation.
    Additional Benefits - Acupuncture
    This plan does not cover Acupuncture.

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