2024 Medicare Advantage Plans
PPO and HMO Plans
Coverage you can trust from the doctors you prefer ... and so much more. Check out the plan details, then choose the plan that's right for you. You can enroll today, or call for more information at any time: 1-888-888-8888 (TTY: 711).
| Service Area | Value PPO | Advantage PPO | Advantage Plus PPO | Inspire HMO |
|---|---|---|---|---|
| In Network Out of Network | In Network Out of Network | In Network Out of Network | In Network | |
| Enroll Now | Enroll Now | Enroll Now | Enroll Now | |
| Premium and Out-of-Pocket Limit | ||||
| Monthly Premium | $0 | $0 | $22 | $0 |
| Part B Premium Reduction | $25 | Not applicable | Not applicable | Not applicable |
| Plan Deductible | $0 | $0 | $0 | $0 |
| Annual Maxium Out-of-Pocket Amounts (Includes Medicare Part A and B services) |
$8,500
$8,500 (combined) |
$8,500
$8,500 (combined) |
$6,300
$6,300 (combined) |
$6,300 |
| Doctor Services | ||||
| Primary Care Physician (PCP) Services (Includes Telehealth visits) | $10 $10 | $0 $5 | $0 $5 | $0 |
| Physician Specialist Services (Includes Telehealth visits) | $45 $45 | $40 $40 | $25 $25 | $30 |
| Outpatient Mental Health Visits (Includes Telehealth visits) | $40 $40 | $40 $40 | $25 $25 | $30 |
| Physical, Occupational, and Speech Therapy | $40 $40 | $40 $40 | $25 $25 | $30 |
| Medicare-covered Preventive Services and Annual Routine Physical Exam | $0 $0 | $0 $0 | $0 $0 | $0 |
| Emergency and Urgent Care | ||||
| Emergency Room Visits (Includes worldwide visits) | $100 copay per visit | $100 copay per visit | $120 copay per visit | $120 copay per visit |
| Urgent Care Visits (includes worldwide visits) | $55 copay per visit | $50 copay per visit | $50 copay per visit | $35 copay per visit |
| Worldwide Coverage Annual Maximum (Outside the United States) | $20,000 plan maximum per year | $20,000 plan maximum per year | $20,000 plan maximum per year | $20,000 plan maximum per year |
| Hospital and Outpatient Services | ||||
| Inpatient Hospital Care | $225 copay per day (days 1-4) $225 copay per day (days 1-4) | $150 copay per day (days 1-4) $150 copay per day (days 1-4) | $100 copay per day (days 1-4) $100 copay per day (days 1-4) | $175 copay per stay (days 1-4) |
| Skilled Nursing Facility | $0 copay (days 1-20) $203 copay (days 21-100) |
$0 copay (days 1-20) $203 copay (days 21-100) |
$0 copay (days 1-20) $203 copay (days 21-100) |
$0 copay (days 1-20) $203 copay (days 21-100) |
| Outpatient Hospital Services (Surgery) | $0-$375 copay $0-$375 copay | $0-$375 copay $0-$375 copay | $0-$350 copay $0-$350 copay | $0-$400 copay |
| Ambulatory Surgical Center Services | $0-$350 copay $0-$350 copay | $0-$375 copay $0-$375 copay | $0-$325 copay $0-$325 copay | $0-$225 copay |
| Lab Services | $0-35 copay 20% coinsurance | $0-25 copay 20% coinsurance | $0-20 copay 20% coinsurance | $0-25 copay |
| X-ray Services | $35 copay 20% coinsurance | $20 copay 20% coinsurance | $20 copay 20% coinsurance | $25 copay |
| Diagnostic Radiology (Includes CT, MRI, MRAs, etc.) | $0-285 copay per visit 20% coinsurance | $0-275 copay per visit 20% coinsurance | $0-255 copay per visit 20% coinsurance | $0-175 copay per visit |
| Durable Medical Equipment/Prosthetics | 20% coinsurance | 20% coinsurance | 20% coinsurance | 20% coinsurance |
| Routine Dental, Hearing, and Vision Services | ||||
| Preventive Dental Services (Up to two exams, cleanings, fluoride, and complete set of bite-wing X-rays per year) | $10 copay for exam 50% coinsurance | $10 copay for exam 50% coinsurance | $10 copay for exam 50% coinsurance | $10 copay for exam |
| Comprehensive Dental Services (50% coinsurance includes fillings, extractions, crowns, and most plans include dentures) | $600 Maximum allowance/year | $2,750 Maximum allowance/year | $3,500 Maximum allowance/year | $2,500 Maximum allowance/year |
| Routine Eye Exams (Includes one exam per year) | $10 copay 50% coinsurance | $0 copay 50% coinsurance | $0 copay 50% coinsurance | $0 copay |
| Routine Eyewear (Includes eyewear [frames and lenses] or contact lenses) | $100 max allowance every year | $150 max allowance/year | $225 max allowance/year | $150 max allowance every year (in-network only) |
| Rountine Hearing Exams (Includes one exam and one fitting per year) | $0 copay 50% coinsurance | $0 copay 50% coinsurance | $0 copay 50% coinsurance | $0 copay |
| Prescription Hearing Aids | $400 Maximum allowance/year | $800 Maximum allowance/year | $1,000 Maximum allowance/year | $800 Maximum allowance/year |
| OTC Hearing Aids | $100 Maximum allowance/year | $150 Maximum allowance/year | $200 Maximum allowance/year | $150 Maximum allowance/year |
| Flexible Spending Allowance - My Flex Benefit Card (May be used toward covered routine and comprehensive dental, routine vision and eyewear, or routine hearing and hearing aid services) | $400 allowance/year | Not applicable | Not applicable | Not applicable |
| Supplemental Benefits | ||||
| Fitness Benefit | $0 copay for SilverSneakers® | $0 copay for SilverSneakers® | $0 copay for SilverSneakers® | $0 copay for SilverSneakers® |
| VirtualCare Visits (Must use WellSpan Health Virtual Care) | $0 copay | $0 copay | $0 copay | $0 copay |
| Transportation Services (Plan approved trips) | Not covered | $0 copay Limit 16 one-way trips/year | $0 copay Limit 24 one-way trips/year | $0 copay Limit 24 one-way trips/year |
| Over The Counter (OTC) Items | $75 OTC allowance per quarter through participating retailers or mail-order | $75 OTC allowance per quarter through participating retailers or mail-order | $110 OTC allowance per quarter through participating retailers or mail-order | $75 OTC allowance per quarter through participating retailers or mail-order |
| Healthy Food and Produce (Available to members with qualifying chronic conditions) | Not covered | $60 allowance per quarter through participating retailers | $60 allowance per quarter through participating retailers | $60 allowance per quarter through participating retailers |
| Prescription Drug - Retail Pharmacy | ||||
| Part D Drug Deductible | $0 deductible | $0 deductible | $0 deductible | $0 deductible |
| Tier 1 - Preferred Generic Drugs | 30 day Prf $0 / Stnd $12 90 day Prf $0 / Stnd $36 |
30 day Prf $0 / Stnd $12 90 day Prf $0 / Stnd $36 |
30 day Prf $0 / Stnd $10 90 day Prf $0 / Stnd $30 |
30 day Prf $0 / Stnd $10 90 day Prf $0 / Stnd $30 |
| Tier 2 - Generic Drugs | 30 day Prf $12 / Stnd $20 90 day Prf $36 / Stnd $60 |
30 day Prf $10 / Stnd $20 90 day Prf $30 / Stnd $60 |
30 day Prf $0 / Stnd $20 90 day Prf $0 / Stnd $60 |
30 day Prf $5 / Stnd $15 90 day Prf $15 / Stnd $45 |
| Tier 3 - Preferred Brand Drugs | 30 day Prf / Stnd $47 90 day Prf / Stnd $141 |
30 day Prf / Stnd $47 90 day Prf / Stnd $141 |
30 day Prf / Stnd $47 90 day Prf / Stnd $141 |
30 day Prf / Stnd $47 90 day Prf / Stnd $141 |
| Tier 4 - Non-Preferred Drugs | 30 day Prf / Stnd $100 90 day Prf / Stnd $300 |
30 day Prf / Stnd $100 90 day Prf / Stnd $300 |
30 day Prf / Stnd $100 90 day Prf / Stnd $300 |
30 day Prf / Stnd $100 90 day Prf / Stnd $300 |
| Tier 5 - Specialty Drugs 30 day ONLY |
33% coinsurance | 33% coinsurance | 33% coinsurance | 33% coinsurance |
| Part D Insulin Saver | 30 day Prf / Stnd $35 90 day Prf / Stnd $105 |
30 day Prf / Stnd $35 90 day Prf / Stnd $105 |
30 day Prf / Stnd $35 90 day Prf / Stnd $105 |
30 day Prf / Stnd $35 90 day Prf / Stnd $105 |
| Initial Coverage Limit Maximum | $5,030 | $5,030 | $5,030 | $5,030 |
| Coverage Gap | ||||
| Generic and Brand Drugs (Tiers 1 through 5) |
25% coinsurance | 25% coinsurance | 25% coinsurance | 25% coinsurance |
| True Out-of-Pocket (TrOOP) Maximum | $8,000 | $8,000 | $8,000 | $8,000 |
| Enroll Now | Enroll Now | Enroll Now | Enroll Now | |
