Independent Health s Medicare Passport Access (PPO)
H3344 - 012 - 0
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Independent Health s Medicare Passport Access (PPO) is a Medicare Advantage Plan by Independent Health.
This page features plan details for 2024 Independent Health s Medicare Passport Access (PPO) H3344 – 012 – 0 available in Western New York.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Independent Health s Medicare Passport Access (PPO) is offered in the following locations.
Plan Overview
Independent Health s Medicare Passport Access (PPO) offers the following coverage and cost-sharing.
| Insurer: | Independent Health |
| Health Plan Deductible: | $0.00 |
| MOOP: | $12,500 In and Out-of-network $7,500 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $250.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Independent Health s Medicare Passport Access (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Independent Health s Medicare Passport Access (PPO) has a monthly premium of $10.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $10.00 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Independent Health s Medicare Passport Access (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $250.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $10.00 | $ |
Initial Coverage Phase
After you pay your $250.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | |||
| 2 (Generic) | $17.00 copay | |||
| 3 (Preferred Brand) | $47.00 copay | |||
| 4 (Non-Preferred Drug) | 48% | |||
| 5 (Specialty Tier) | 29% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $42.50 copay | $42.50 copay | ||
| 3 (Preferred Brand) | $117.50 copay | $117.50 copay | ||
| 4 (Non-Preferred Drug) | 48% | 48% | ||
| 5 (Specialty Tier) |
Gap Coverage Phase
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
Independent Health s Medicare Passport Access (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $12,500 In and Out-of-network $7,500 In-network |
| No |
| In-network | Yes, contact plan for further details |
| In-network | $375 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 40% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | 40% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | 40% coinsurance per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | 0-20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $225 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0-40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $45 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | 40% coinsurance (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $499-2,199 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $499-2,199 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Office visit | $0.00 (Authorization is not required.) (Referral is not required.) |
| out-of-network Office visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| Oral exam | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Restorative services | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $65 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $275 copay (Not applicable.) (Not applicable.) |
| out-of-network | $275 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 10-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 50% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 50% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| out-of-network Diabetes supplies | 40% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $325 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | 40% per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $375 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 40% per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 40% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 40% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Independent Health s Medicare Passport Access (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Table of Contents
Need more information on Independent Health s Medicare Passport Access (PPO)? See 2025 Independent Health s Medicare Passport Access (PPO) at MedicareAdvantageRX.com.
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