Transcription
SUMMARY OF BENEFITS2021 Advantage MD Health PlansJOHNS HOPKINS ADVANTAGE MD (HMO)JOHNS HOPKINS ADVANTAGE MD (PPO)JOHNS HOPKINS ADVANTAGE MD PLUS (PPO)JOHNS HOPKINS ADVANTAGE MD PREMIER (PPO)H1225 001H1225 002H3890 001H3890 002H3890 004Y0124 SOB0720 M Accepted
Section I: Introduction to Summary of BenefitsJanuary 1, 2021 – December 31, 2021This booklet gives you a summary of what we cover and whatyou pay. It doesn’t list every service that we cover or list everylimitation or exclusion. To get a complete list of services wecover, call us or go online to view the “Evidence of Coverage.”You have choices about how to get your Medicare benefitsOne choice is to get your Medicare benefits through OriginalMedicare (fee-for-service Medicare). Original Medicare is rundirectly by the Federal government. Another choice is to getyour Medicare benefits by joining a Medicare health plan (suchas Johns Hopkins Advantage MD (PPO), Johns HopkinsAdvantage MD Plus (PPO), Johns Hopkins Advantage MDPremier (PPO), or Johns Hopkins Advantage MD (HMO).Tips for comparing your Medicare choices:If you want to compare our plans with other Medicare healthplans, ask the other plans for their Summary of Benefitsbooklets. Or, use the Medicare Plan Finder onwww.medicare.gov. If you want to know more about thecoverage and costs of Original Medicare, look in your current“Medicare & You” handbook. View it online atwww.medicare.gov or get a copy by calling 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY usersshould call 1-877-486-2048.Sections in this booklet Things to Know About Our Plans Monthly Premium, Deductible, and Limits on How MuchYou Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug BenefitsThis document is available in other formats, such as braille andlarge print. For additional information, call us at 1-888-403-7662(TTY: 711).Things to Know About Our Plans:Hours of OperationFrom October 1 to March 31, you can call us 7 days a weekfrom 8:00 a.m. to 8:00 p.m. Eastern time.From April 1 to September 30, you can call us Monday throughFriday from 8:00 a.m. to 8:00 p.m. Eastern time.Johns Hopkins Advantage MD and Johns HopkinsAdvantage MD Plus, and Johns Hopkins Advantage MDPremier Phone Numbers:If you are a member of these plans, call toll-free1-877-293-5325 (TTY: 711). If you are not a member of theseplans, call toll-free 1-888-403-7662 (TTY: 711).Johns Hopkins Advantage MD (HMO) Phone Number:If you are a member of this plan, call toll-free 1-877-293-4998(TTY: 711). If you are not a member of this plan, call toll-free1-888-403-7662 (TTY: 711).Our plan website: www.HopkinsMedicare.com2 ADVANTAGE MD – SUMMARY OF BENEFITS
Who can join?To join, you must be entitled to Medicare Part A, be enrolled inMedicare Part B, and live in the plan’s service area.The Johns Hopkins Advantage MD (HMO) service area includesthe following counties in Maryland: Anne Arundel, Baltimore,Baltimore City, Calvert, Carroll, Frederick, Howard,Montgomery, Somerset, Washington, Wicomico, and Worcester.The Johns Hopkins Advantage MD (PPO) and Johns HopkinsAdvantage MD Plus (PPO) service area include the followingcounties in Maryland: Anne Arundel, Baltimore, Baltimore City,Calvert, Carroll, Frederick, Howard, Somerset, Washington,Wicomico, and Worcester. (Not available in MontgomeryCounty.)The Johns Hopkins Advantage MD Premier (PPO) service areaincludes Montgomery County only.All PPO members:If you use the providers in our network, you may pay less foryour covered services. But if you want to, you can also useproviders that are not in our network.All HMO members:If you use providers that are not in our network, the plan maynot pay for these services. Referrals are required for specialtycare only.All members:You must generally use network pharmacies to fill yourprescriptions for covered Part D drugs. You can see our plan’sprovider and pharmacy directory at our website(www.HopkinsMedicare.com). Or, call us and we will send you acopy of the provider and pharmacy directories.What do we cover?Like all Medicare health plans, we cover everything that OriginalMedicare covers and more. Our plan members get all of thebenefits covered by Original Medicare. For some of thesebenefits, you may pay more in our plan than you would inOriginal Medicare. For others, you may pay less. Our planmembers also get more than what is covered by OriginalMedicare. Our plans may offer supplemental benefits in additionto Part C benefits and Part D benefits. Some of the extrabenefits are outlined in this booklet. We cover Part D drugs. Inaddition, we cover Part B drugs, such aschemotherapy/radiation and some drugs administered by yourprovider. You can see the complete plan formulary (list of Part Dprescription drugs) and any restrictions on our website,www.HopkinsMedicare.com. Or, call us and we will send you acopy of the formulary.How will I determine my drug costs?Our plan groups each medication into one of five “tiers.” You willneed to use your formulary to locate what tier your drug is on todetermine how much it will cost you. The amount you paydepends on the drug’s tier and what stage of the benefit youhave reached. Later in this document we discuss the benefitstages that occur: Deductible, Initial Coverage, Coverage Gap,and Catastrophic Coverage.ADVANTAGE MD – SUMMARY OF BENEFITS 3
Section II: Summary of BenefitsHMO & PPO PlansBenefits &CoverageAdvantageMD (HMO)Available throughoutservice areaAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyAdvantageMD Premier (PPO)Only available inMontgomery CountyMONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICESMonthly PlanPremium (includingPart C and Part Dpremium, whenapplicable.)Baltimore City: 20 per month. Inaddition, you must keeppaying your MedicarePart B premium. 91 per month. In addition,you must keep paying yourMedicare Part B premium. 121 per month. Inaddition, you must keeppaying your Medicare PartB premium. 351 per month. Inaddition, you must keeppaying your Medicare PartB premium.This plan does not haveany medical deductibles.This plan does not haveany medical deductibles.This plan does not haveany medical deductibles.All other counties: 40 per month. Inaddition, you must keeppaying your MedicarePart B premium.Deductibles,including plan leveland category leveldeductible;This plan does not haveany medical deductibles.4 ADVANTAGE MD – SUMMARY OF BENEFITS
Benefits &CoverageMaximum Out-ofPocketResponsibility(does not includeprescription drugs)AdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyLike all Medicare healthplans, our plan protectsyou by having yearly limitson your out-of-pocket costsfor medical and hospitalcare.Like all Medicare healthplans, our plan protects youby having yearly limits onyour out-of-pocket costs formedical and hospital care.Like all Medicare healthplans, our plan protects youby having yearly limits onyour out-of-pocket costs formedical and hospital care.Like all Medicare healthplans, our plan protects youby having yearly limits onyour out-of-pocket costs formedical and hospital care.Your yearly limit(s) in thisplan:Your yearly limit(s) in thisplan:Your yearly limit(s) in thisplan:Your yearly limit(s) in thisplan: 7,550 for services youreceive from in-networkproviders. 7,550 for services youreceive from in-networkproviders. 7,550 for services youreceive from in-networkproviders. 7,550 for services youreceive from in-networkproviders. 11,300 for services youreceive from any provider.Your limit for servicesreceived from in-networkproviders will count towardthis limit. 11,300 for services youreceive from any provider.Your limit for servicesreceived from in-networkproviders will count towardthis limit. 11,300 for services youreceive from any provider.Your limit for servicesreceived from in-networkproviders will count towardthis limit.AdvantageMD (HMO)Available throughoutservice areaAdvantageMD Premier (PPO)Only available inMontgomery CountyIf you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the fullcost for the rest of the year.Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.Our plan has a coverage limit every year for certain benefits from any provider.ADVANTAGE MD – SUMMARY OF BENEFITS 5
Benefits &CoverageInpatient HospitalCoverage(Services may requirethat your provider getprior authorization(approval in advance).Please see theEvidence of Coveragebooklet for moreinformation.)AdvantageMD (PPO)AdvantageMD Plus (PPO)Available throughoutservice areaReview service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyOur plan covers 90 daysfor each Medicarecovered inpatienthospital stay. (Our planalso covers 60 lifetimereserve days.)Our plan covers 90 days foreach Medicare-covered innetwork or out-of-networkinpatient hospital stay. (Ourplan also covers 60 lifetimereserve days.)Our plan covers 90 days foreach Medicare-covered innetwork or out-of-networkinpatient hospital stay. (Ourplan also covers 60 lifetimereserve days.)Our plan covers 90 days foreach Medicare-covered innetwork or out-of-networkinpatient hospital stay. (Ourplan also covers 60 lifetimereserve days.)You pay a 310 copayeach day for days 1-5 ofa hospital stay.In-network: You pay a 310copay each day for days 16 of a hospital stay.In-network: You pay a 310copay each day for days 16 of a hospital stay.In-network & Out-ofnetwork: You pay a 200copay per admission.Out-of-network: 30%coinsuranceOut-of-network: 30%coinsuranceAdvantageMD (HMO)6 ADVANTAGE MD – SUMMARY OF BENEFITSAdvantageMD Premier (PPO)Only available inMontgomery County
Benefits &CoverageAdvantageMD (HMO)Available throughoutservice areaOutpatient HospitalCoverage(Services mayrequire that yourprovider get priorauthorization(approval inadvance). Pleasesee the Evidence ofCoverage booklet formore information.) 300 copayAmbulatorySurgery Center(Services mayrequire that yourprovider get priorauthorization(approval inadvance). Pleasesee the Evidence ofCoverage booklet formore information.) 225 copayAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyIn-network: 300 copayIn-network: 300 copayOut-of-network: 50%coinsuranceOut-of-network: 50%coinsuranceIn-network: 225 copayIn-network: 225 copayOut-of-network: 50%coinsuranceOut-of-network: 50%coinsuranceAdvantageMD Premier (PPO)Only available inMontgomery CountyIn-network & Out-ofnetwork: 100 copayIn-network & Out-ofnetwork: 50 copayADVANTAGE MD – SUMMARY OF BENEFITS 7
Benefits &CoverageDoctor Visits Primary CareProviders SpecialistsPreventative Care(e.g. flu vaccine,diabetic screenings)AdvantageMD (HMO)Available throughoutservice area 5 copay 50 copayYou pay nothingAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyIn-network: 10 copayIn-network: 5 copayOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceIn-network: 50 copayIn-network: 50 copayOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceIn-network: You paynothingIn-network: You paynothingOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceOur plan covers many preventive services, including:Abdominal aortic aneurysm screeningAnnual routine physical examAnnual wellness visitBarium enemasBone mass measurement (bone density)Breast cancer screening (mammogram)Cardiovascular disease risk reduction visit (therapy for cardiovascular disease)Cardiovascular disease testingCervical and vaginal cancer screeningColorectal cancer screenings (colonoscopy, FOBT and FIT kit)Depression screeningDiabetes screenings8 ADVANTAGE MD – SUMMARY OF BENEFITSAdvantageMD Premier (PPO)Only available inMontgomery CountyIn-network & Out-ofnetwork: You pay nothingIn-network & Out-ofnetwork: 10 copayIn-network & Out-ofnetwork: You pay nothing
Benefits &CoveragePreventative Care(continued)AdvantageMD (HMO)Available throughoutservice areaAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyAdvantageMD Premier (PPO)Only available inMontgomery CountyDiabetes self-management training, diabetic services, and suppliesDigital rectal examsEKG following a Welcome VisitHealth and wellness education programsHIV screeningImmunizationsMedical nutrition therapy servicesMedicare diabetes prevention program (MDPP)Obesity screening and therapy to promote sustained weight lossProstate cancer screening examsScreening and counseling to reduce alcohol misuseScreening for lung cancer with low dose computed tomography (LDCT)Screening for Sexually transmitted infections (STIs) and counseling to prevent STIsSmoking and tobacco use cessation (Counseling to stop smoking or tobacco use)Vision care“Welcome to Medicare” preventive visit (one-time)Any additional preventive services approved by Medicare during the contract year will be covered.ADVANTAGE MD – SUMMARY OF BENEFITS 9
Benefits &CoverageAdvantageMD (HMO)Available throughoutservice areaAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyAdvantageMD Premier (PPO)Only available inMontgomery CountyEmergency Care 90 copayThe copay is waived ifyou are admitted to thehospital within 24 hoursfor the same condition.Emergency care iscovered in the UnitedStates only.In-network & Out-ofnetwork: 90 copayThe copay is waived if youare admitted to the hospitalwithin 24 hours for the samecondition. Emergency care iscovered in the United Statesonly.In-network & Out-ofnetwork: 90 copayThe copay is waived if youare admitted to the hospitalwithin 24 hours for thesame condition. Emergencycare is covered worldwide.In-network & Out-ofnetwork: 90 copayThe copay is waived if youare admitted to the hospitalwithin 24 hours for thesame condition. Emergencycare is covered worldwide.Urgently NeededServices 40 copayThe copay is not waivedif you are admitted to thehospital. Urgentlyneeded services arecovered in the UnitedStates only.In-network & Out-ofnetwork: 40 copayThe copay is not waived ifyou are admitted to thehospital. Urgently neededservices are covered in theUnited States only.In-network & Out-ofnetwork: 40 copayThe copay is not waived ifyou are admitted to thehospital. Urgently neededservices are coveredworldwide.In-network & Out-ofnetwork: 20 copayThe copay is not waived ifyou are admitted to thehospital. Urgently neededservices are b services (e.g. Bloodcount, stool tests,creatinine, blood glucose):You pay nothingLab services (e.g. Bloodcount, stool tests,creatinine, blood glucose):In-network: You paynothingLab services (e.g. Bloodcount, stool tests,creatinine, blood glucose):In-network: You paynothingLab services (e.g. Bloodcount, stool tests,creatinine, blood glucose):In-network & Out-ofnetwork: You pay nothingOut-of-network: 50%coinsuranceOut-of-network: 30%coinsurance10 ADVANTAGE MD – SUMMARY OF BENEFITS
Benefits &CoverageDiagnosticServices/Labs/Imaging (continued)(Services mayrequire that yourprovider get priorauthorization(approval inadvance). Pleasesee the Evidence ofCoverage booklet formore information.)AdvantageMD (HMO)Available throughoutservice areaDiagnostic tests andprocedures (e.g.Biopsies, Endoscopies,cat scans):20% coinsuranceDiagnostic x-rays (suchas mammography andultrasound): 20 copayDiagnostic radiologyservices (such as MRIsand CT scans): 175 copayTherapeutic radiologyservices (such asradiation treatment forcancer):20% coinsuranceAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyDiagnostic tests andprocedures (e.g. Biopsies,Endoscopies, cat scans):In-network: 20%coinsuranceDiagnostic tests andprocedures (e.g. Biopsies,Endoscopies, cat scans):In-network: 20%coinsuranceOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceDiagnostic x-rays (suchas mammography andultrasound):In-network: 30 copayDiagnostic x-rays (suchas mammography andultrasound):In-network: 30 copayOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceDiagnostic radiologyservices (such as MRIsand CT scans):In-network: 250 copayDiagnostic radiologyservices (such as MRIsand CT scans):In-network: 250 copayOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceTherapeutic radiologyservices (such as radiationtreatment for cancer):In-network: 20%coinsuranceTherapeutic radiologyservices (such as radiationtreatment for cancer):In-network: 20%coinsuranceOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceAdvantageMD Premier (PPO)Only available inMontgomery CountyDiagnostic tests andprocedures (e.g. Biopsies,Endoscopies, cat scans):In-network & Out-ofnetwork: 10 copayDiagnostic x-rays (suchas mammography andultrasound):In-network & Out-ofnetwork: 10 copayDiagnostic radiologyservices (such as MRIsand CT scans):In-network & Out-ofnetwork: 100 copayTherapeutic radiologyservices (such as radiationtreatment for cancer):In-network & Out-ofnetwork: 20% coinsuranceADVANTAGE MD – SUMMARY OF BENEFITS 11
Benefits &CoverageHearing Services Routinehearing examHearing aidsAdvantageMD (HMO)Available throughoutservice areaAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyMedicare-covered examto diagnose and treathearing and balanceissues:In-network: 50 copayMedicare-covered examto diagnose and treathearing and balanceissues:In-network: 40 copayOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceRoutine hearing exam:You pay nothing(one routine hearingexam per year from aTruHearing provider)Routine hearing exam:In-network: You paynothing (one routinehearing exam per year)Routine hearing exam:In-network: You paynothing (one routinehearing exam per year)Out-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceHearing aids:You pay a 699 copayper aid for Advancedhearing aids or 999copay per aid forPremium hearing aids.for up to two TruHearingbranded hearing aidsevery year (one per earper year).Hearing aids:In-network & Out-ofnetwork: You pay a 699copay per aid for Advancedhearing aids or 999 copayper aid for Premiumhearing aids for up to twoTruHearing-brandedhearing aids every year(one per ear per year).Hearing aids:In-network & Out-ofnetwork: You pay a 699copay per aid for Advancedhearing aids or 999 copayper aid for Premiumhearing aids for up to twoTruHearing-brandedhearing aids every year(one per ear per year).Medicare-coveredexam to diagnose andtreat hearing andbalance issues: 50 copay12 ADVANTAGE MD – SUMMARY OF BENEFITSAdvantageMD Premier (PPO)Only available inMontgomery CountyMedicare-covered examto diagnose and treathearing and balanceissues:In-network & Out-ofnetwork: 10 copayRoutine hearing exam:In-network & Out-ofnetwork: You pay nothing(In-network coveredthrough TruHearingprovider and is limited to 1exam per year.)Hearing aids:In-network & Out-ofnetwork: You pay a 399copay per aid for Advancedhearing aids or 699 copayper aid for Premiumhearing aids for up to twoTruHearing-brandedhearing aids every year(one per ear per year).
Benefits &CoverageDental Services Oral exam &cleaning Optionalsupplementalbenefits(availableonly withAdvantageMD HMO,PPO, andPlus PPO)(Non-Medicarecoveredcomprehensiveservices may requirethat your providerget priorauthorization(approval inadvance). Pleasesee the Evidence ofCoverage booklet formore information.)AdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyMedicare-covered dentalservices:In-network:20% coinsuranceMedicare-covered dentalservices:In-network:20% coinsuranceOut-of-network: 50%coinsuranceOut-of-network: 50%coinsurancePreventive dentalservices:Cleaning(s) (1 cleaningper year): 15 copayPreventive dental services:Cleaning(s) (1 cleaning peryear):In-network: 15 copayPreventive dental services:Cleaning(s) (2 cleanings peryear):In-network: 10 copayOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceFluoride treatments:Not covered.Fluoride treatments:Not covered.Fluoride treatments:Not covered.Fluoride treatments:(2 fluoride treatments peryear):In-network & Out-of-network:You pay nothingDental X-ray(s)(Frequency determined bytype of X-ray): 25 copayDental X-ray(s) (Frequencydetermined by type of X-ray):In-network: 25 copayDental X-ray(s) (Frequencydetermined by type of X-ray):In-network: 20 copayDental X-ray(s) (Frequencydetermined by type of X-ray):In-network & Out-of-network:You pay nothingOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceAdvantageMD (HMO)Available throughoutservice areaMedicare-covered dentalservices:20% coinsuranceAdvantageMD Premier (PPO)Only available inMontgomery CountyMedicare-covered dentalservices:In-network & Out-of-network: 10 copayPreventive dental services:Cleaning(s) (2 cleanings peryear):In-network & Out-of-network:You pay nothingADVANTAGE MD – SUMMARY OF BENEFITS 13
Benefits &CoverageDental Services(continued)AdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyOral exam(s) (Frequencydetermined by type of oralexam):In-network: 15 copayOral exam(s) (Frequencydetermined by type of oralexam):In-network: 10 copayOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceComprehensive dentalservices:Not covered.Comprehensive dentalservices:Not covered.Comprehensive dentalservices:Not covered.Optional SupplementalBenefit:For an extra 30 permonth, members canpurchase a supplementalbenefit that includes bothcomprehensive dental andfitness benefits.Optional SupplementalBenefit:For an extra 30 per month,members can purchase asupplemental benefit thatincludes both comprehensivedental and fitness benefits.Optional SupplementalBenefit:For an extra 28 per month,members can purchase asupplemental comprehensivedental benefit.The comprehensive dentaland fitness benefits cannotbe purchased separately.The comprehensive dentalbenefit has a maxcoverage amount of 1,200 per year.The comprehensive dentaland fitness benefits cannotbe purchased separately.The comprehensive dentalbenefit has a max coverageamount of 1,200 per year.The comprehensive dentalbenefit has a max coverageamount of 1,200 per year.AdvantageMD (HMO)Available throughoutservice areaOral exam(s) (Frequencydetermined by type of oralexam): 15 copay14 ADVANTAGE MD – SUMMARY OF BENEFITSAdvantageMD Premier (PPO)Only available inMontgomery CountyOral exam(s) (Frequencydetermined by type of oralexam):In-network & Out-of-network:You pay nothingComprehensive dentalservices: (Frequencydependent on procedure.)Restorative services (suchas inlays, onlays, crowns,resin restoration, etc.)In-network & Out-of-network:20-50% coinsurancedepending on the serviceEndodontics (such as rootcanals, retreatment,apicoectomy, pulpotomy,etc.)In-network & Out-of-network:50% coinsurance
Benefits &CoverageDental Services(continued)AdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyThe followingcomprehensive dentalservices are covered aspart of the OptionalSupplemental Benefitspackage (available withadditional premium):The following comprehensivedental services are coveredas part of the OptionalSupplemental Benefitspackage (available withadditional premium):The following comprehensivedental services are coveredas part of the OptionalSupplemental Benefitspackage (available withadditional premium):Restorative services(such as inlays, onlays,crowns, resin restoration,etc.)Restorative services (suchas inlays, onlays, crowns,resin restoration, etc.)Restorative services (suchas inlays, onlays, crowns,resin restoration, etc.)Frequency dependent onprocedure.Frequency dependent onprocedure.In-network: 50- 400 copaydepending on the serviceIn-network: 50- 400 copaydepending on the serviceOut-of-network: 50-70%coinsurance depending onthe serviceOut-of-network: 50-70%coinsurance depending onthe serviceEndodontics (such asroot canals, retreatment,apicoectomy, etc.)Endodontics (such as rootcanals, retreatment,apicoectomy, etc.)Endodontics (such as rootcanals, retreatment,apicoectomy, etc.)Frequency dependent onprocedure.Frequency dependent onprocedure.Frequency dependent onprocedure.In-network: 200 copayIn-network: 200 copayIn-network: 200 copayAdvantageMD (HMO)Available throughoutservice areaFrequency dependent onprocedure.In-network: 50- 400copay depending on theserviceOut-of-network: 50-70%coinsurance depending onthe serviceAdvantageMD Premier (PPO)Only available inMontgomery CountyPeriodontics (such asperiodontal maintenance,periodontal scaling, rootplanning, full mouthdebridement, etc.)In-network & Out-of-network:0-50% coinsurancedepending on the serviceExtractions (such asextractions, coronectomy,etc.)In-network & Out-of-network:20% coinsuranceADVANTAGE MD – SUMMARY OF BENEFITS 15
Benefits &CoverageDental Services(continued)AdvantageMD (HMO)Available throughoutservice areaAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyOut-of-network: 50%coinsuranceOut-of-network: 50%coinsuranceOut-of-network: 50%coinsurancePeriodontics (such asperiodontal maintenance,periodontal scaling, rootplanning, etc.)Periodontics (such asperiodontal maintenance,periodontal scaling, rootplanning, etc.)Periodontics (such asperiodontal maintenance,periodontal scaling, rootplanning, etc.)Frequency dependent onprocedure.Frequency dependent onprocedure.Frequency dependent onprocedure.In-network: 50 copayIn-network: 50 copayIn-network: 50 copayOut-of-network: 50%coinsuranceOut-of-network: 50%coinsuranceOut-of-network: 50%coinsuranceExtractions (such asextractions, coronectomy,surgical access of anunerupted tooth, etc.)Extractions (such asextractions, coronectomy,surgical access of anunerupted tooth, etc.)Extractions (such asextractions, coronectomy,surgical access of anunerupted tooth, etc.)Frequency dependent onprocedure.Frequency dependent onprocedure.Frequency dependent onprocedure.In-network: 50 copayIn-network: 50 copayIn-network: 50 copayOut-of-network: 50%coinsuranceOut-of-network: 50%coinsuranceOut-of-network: 50%coinsurance16 ADVANTAGE MD – SUMMARY OF BENEFITSAdvantageMD Premier (PPO)Only available inMontgomery CountyProsthodontics/ Otheroral/maxillofacial surgery/Other services (such asremovable complete andpartial dentures, repair orreplace teeth in dentures,consultation, anesthesia,etc.)Frequency dependent onprocedure.In-network & Out-of-network:0-50% coinsurancedepending on the serviceThe plan has a maximumcoverage amount of 1,500per year for in- and out-ofnetwork non-Medicarecovered comprehensivedental services.
Benefits &CoverageDental Services(continued)AdvantageMD (HMO)Available throughoutservice areaProsthodontics/ Otheroral/maxillofacialsurgery/ Other services(such as removablecomplete and partialdentures, repair or replaceteeth in dentures, removalof exostosis, anesthesia,etc.)Frequency dependent onprocedure.In-network: 50- 400copay depending on theserviceOut-of-network: 50-70%coinsurance depending onthe serviceAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyProsthodontics/ Otheroral/maxillofacial surgery/Other services (such asremovable complete andpartial dentures, repair orreplace teeth in dentures,removal of exostosis,anesthesia, etc.)Prosthodontics/ Otheroral/maxillofacial surgery/Other services (such asremovable complete andpartial dentures, repair orreplace teeth in dentures,removal of exostosis,anesthesia, etc.)Frequency dependent onprocedure.Frequency dependent onprocedure.In-network: 50- 400 copaydepending on the serviceIn-network: 50- 400 copaydepending on the serviceOut-of-network: 50-70%coinsurance depending onthe serviceOut-of-network: 50-70%coinsurance depending onthe service 1,200 per year 1,200 per yearMedicare-covered exam todiagnose and treatdiseases and conditions ofthe eye (including yearlyglaucoma screening):In-network: 50 copay.Medicare-covered exam todiagnose and treatdiseases and conditions ofthe eye (including yearlyglaucoma screening):In-network: 40 copay.AdvantageMD Premier (PPO)Only available inMontgomery County 1,200 per yearVision ServicesMedicare-covered examto diagnose and treatdiseases and conditionsof the eye (includingyearly glaucomascreening): 50 copay.Medicare-covered exam todiagnose and treatdiseases and conditions ofthe eye (including yearlyglaucoma screening):In-network & Out-of-network: 10 copay.ADVANTAGE MD – SUMMARY OF BENEFITS 17
Benefits &CoverageAdvantageMD (HMO)Available throughoutservice areaVision Services(continued)Routine eye exam (1every year): 50 copay.Eyeglasses or contactlenses after cataractsurgery:You pay nothingRoutine eyewear:Our plan pays up to 150every two years forsupplemental eyewear(retail or online) from anyprovider.18 ADVANTAGE MD – SUMMARY OF BENEFITSAdvantageMD (PPO)AdvantageMD Plus (PPO)Review service area. Notavailable in MontgomeryCountyReview service area. Notavailable in MontgomeryCountyOut-of-network: 50%coinsuranceOut-of-network: 30%coinsuranceRoutine eye exam (1 everyyear):In-network: You pay nothingRoutine eye exam (1 everyyear):In-network: You pay nothingOut-of-network: 50%coinsuranceO
JOHNS HOPKINS ADVANTAGE MD PLUS (PPO) JOHNS HOPKINS ADVANTAGE MD PREMIER (PPO) 2021 Advantage MD Health Plans H1225_001 H1225_002 . Medicare Part B, and live in the plan's service area. The Johns Hopkins Advantage MD (HMO) service area includes . determine how much it will cost you. The amount you pay depends on the drug's tier and what .
