Independent Health's Medicare Passport Prime (PPO)

Independent Health's Medicare Passport Prime (PPO) H3344-010 Plan Details
4.5 out of 5 stars

Independent Health's Medicare Passport Prime (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Independent Health.
Plan ID: H3344-010.

$225.00
Monthly Premium

Independent Health's Medicare Passport Prime (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Independent Health.
Plan ID: H3344-010.

Independent Health's Medicare Passport Prime (PPO) H3344-010 Plan Details
4.5 out of 5 stars

Independent Health's Medicare Passport Prime (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Independent Health.
Plan ID: H3344-010.

$225.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $6900
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $45.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $45.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$210.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Maximum out of Pocket $1470.00 every year
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent Care
Copayment for Urgent Care $65.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $65.00
Maximum Plan Benefit of $10,000
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $200.00
Coinsurance for Worldwide Emergency Transportation 20%
Maximum Plan Benefit of $10,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Authorization is required for planned transportation only. Wheelchair van is not covered. Copayment applies for evaluation and treatment or transportation to the hospital for each separarte Medicare-covered service.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $200.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Independent Health's Medicare Passport Prime (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 40%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 10% to 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $30.00
Copayment for Medicare-covered Lab Services $5.00
Coinsurance for Medicare-covered Lab Services 20%
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $100.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $30.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20%
Coinsurance for Medicare Covered Lab Services 20%
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 40%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$270.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $275.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $210.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $225.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 40%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $25.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $25.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $30.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 40%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Office Visit $0.00
Office Vists include:
  • Oral Exams(Max 2(Please see Evidence of Coverage for details))
  • Prophylaxis (Cleaning)(Max 2 every year)
  • Fluoride Treatment(Max 2 every year)
  • Dental X-Rays(Max 2(Please
    • Maximum 2 visits (Please see Evidence of Coverage for details)

    Comprehensive Dental:
    Copayment for Medicare-covered Benefits $30.00 to $275.00
    Coinsurance for Restorative Services 50%
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Coinsurance for Endodontics 50%
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Coinsurance for Periodontics 50%
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Coinsurance for Extractions 50%
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 50%
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Maximum Plan Benefit of $3000.00 every year for Non-Medicare Covered Comprehensive
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $45.00
Coinsurance for Medicare Covered Comprehensive Dental 20%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $20.00
Coinsurance for Non-Medicare Covered Preventive Dental 50%
Coinsurance for Non-Medicare Covered Comprehensive Dental 50%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair
Maximum Plan Benefit of $200.00 for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $45.00
Copayment for Medicare Covered Eyewear $0.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $65.00
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Hearing Exams $0.00 to $30.00
Copayment for Fitting/Evaluation for Hearing Aid $45.00

Hearing Aids:
Copayment for Hearing Aids $499.00 to $2799.00
Copayment Structure per hearing aid: $499, $799, $999, $1,499, or $2,799. Benefit is limited to preferred hearing aids, which come in various styles and colors. You must see a network provider to use this benefit. Member cannot combine any promotional offers with our Hearing Aid benefit.
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $45.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $45.00
Copayment for Non-Medicare Covered Hearing Aids $499.00 to $2799.00

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 20%