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Vermont Blue Advantage Unity HMO (HMO)

H9489 - 001 - 0

(3.5 / 5)

Vermont Blue Advantage Unity HMO (HMO) is a Medicare Advantage Plan by Vermont Blue Advantage.

This page features plan details for 2025 Vermont Blue Advantage Unity HMO (HMO) H9489 – 001 – 0 available in State of Vermont.

Locations

Vermont Blue Advantage Unity HMO (HMO) is offered in the following locations.

Addison County, Vermont

Bennington County, Vermont

Caledonia County, Vermont

Click to see more locations

Plan Overview

Vermont Blue Advantage Unity HMO (HMO) offers the following coverage and cost-sharing.

Insurer:	Vermont Blue Advantage
Health Plan Deductible:	$0
MOOP:	$6,000 In-network
Drugs Covered:	Yes

Ready to sign up for Vermont Blue Advantage Unity HMO (HMO) ?

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

Vermont Blue Advantage Unity HMO (HMO) has a monthly premium of $0.00. 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
$185.00	$0.00	$0.00	$	$

Please Note:

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

Vermont Blue Advantage Unity HMO (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$250.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

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
$0.00	$0.00

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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$10.00 Copay	$10.00 Copay
3) Preferred Brand	$47.00 Copay	$47.00 Copay
4) Non-Preferred Drug	$100.00 Copay	$100.00 Copay

60 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$20.00 Copay	$20.00 Copay
3) Preferred Brand	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	$200.00 Copay	$200.00 Copay

90 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$30.00 Copay	$25.00 Copay
3) Preferred Brand	$141.00 Copay	$117.50 Copay
4) Non-Preferred Drug	$300.00 Copay	$250.00 Copay

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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

Vermont Blue Advantage Unity HMO (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Endodontics
- In-Network: No Coins – No Co pay
Oral and Maxillofacial Surgery
- In-Network: No Coins – No Co pay (Limits Apply)
Periodontics
- In-Network: No Coins – No Co pay
Prosthodontics, fixed
- In-Network: No Coins – No Co pay
Prosthodontics, removable
- In-Network: No Coins – No Co pay
Restorative Services
- In-Network: No Coins – No Co pay

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Outpatient x-rays
- $10 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- $0-300 copay (Authorization Required)
Lab services
- $5 copay (Authorization Required)
Diagnostic tests and procedures
- $0-50 copay (Authorization Required)

Doctor visits

Primary
- $0 copay
Specialist
- $55 copay per visit

Emergency care/Urgent care

Emergency
- $125 copay per visit (always covered)
Urgent care
- $30 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $55 copay
Routine foot care
- Not covered

Ground ambulance

- $350 copay

Health plan deductible

- $0

Hearing

Fitting/evaluation
- $0 copay (Limits Apply)
Hearing aids
- $0 copay (Limits Apply)
Medicare-Covered Hearing Exam
- $0-55 copay
Hearing aids OTC
- Not covered

Inpatient hospital coverage

- $450 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $6,000 In-network

Medical equipment/supplies

Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- 0-20% coinsurance per item (Authorization Required)
Diabetes supplies
- $0 copay

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance (Authorization Required)
Other Part B drugs
- 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient group therapy visit with a psychiatrist
- $20 copay
Inpatient hospital – psychiatric
- $450 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required)
Outpatient group therapy visit
- $20 copay
Outpatient individual therapy visit
- $20 copay
Outpatient individual therapy visit with a psychiatrist
- $20 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $350 copay per visit (Authorization Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $35 copay
Occupational therapy visit
- $35 copay

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $195 per day for days 21 through 55
  $0 per day for days 56 through 100 (Authorization Required)

Transportation

- Not covered

Vision

Other
- Not covered
Routine eye exam
- $0 copay (Limits Apply)
Contact lenses
- $0 copay (Limits Apply)
Eyeglass frames
- $0 copay (Limits Apply)
Eyeglass lenses
- $0 copay (Limits Apply)
Upgrades
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered