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Select (HMO)
Coverage Details
| Medical | |
|---|---|
| Medical Deductible | This plan does not have any medical deductibles. |
| Primary Care Provider Visit | $0 copay |
| Specialist Visit | $45-$50 copay |
| Referrals | Required for Specialist Visits only. |
| Urgent Care | $45 copay |
| Telehealth | $0 copay |
| Ambulatory Surgical Centers Outpatient Surgery | $280 copay |
| Emergency Care | $110 copay |
| Worldwide Emergency & Urgently Needed Services | $110 copay for emergency care services and $45 copay for emergency care services. Inpatient care is not covered. |
| Inpatient Hospital Stay | $350/day copay for days 1-5; $0 copay for days 6-90; Medicare allows 60 “lifetime reserve” days. |
| Routine Podiatry Services | 20% coinsurance (up to 8 times per year). |
| Acupuncture | Medicare covered acupuncture: |
| Routine Chiropractic Services | $15 copay |
| Hearing Aid Services | Medicare-covered hearing exam to diagnose and treat hearing and balance issues: You pay nothing Routine hearing exam Routine hearing exam: You pay nothing (one routine hearing exam per year from a TruHearing provider). Hearing aids Hearing aids: You pay $399 copay per aid for Advanced hearing aids or $699 copay per aid for Premium hearing aids for up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to the TruHearingu2019s Advanced and Premium hearing aids. |
| Silver&Fit® Program | You pay nothing at participating fitness centers. |
| Prescription | |
| Pharmacy Deductible | $590 |
| Preferred Generic (Tier 1) | $0 copay for a one-month supply |
| Generic (Tier 2) | $10 copay for a one-month supply |
| Preferred Brand (Tier 3) | 25% ($35 for Select Insulins) for a one-month supply |
| Non-Preferred Drug (Tier 4) | 25% ($35 for Select Insulins) for a one-month supply |
| Specialty Tier (Tier 5) | 25% of the total cost of a one-month supply (long-term supply is not available) |
| Mail Order | Available |
| Vision | |
| Medicare-covered exam to diagnose and treat diseases and conditions of the eye | $50 copay |
| Yearly Glaucoma Screening | You pay nothing |
| Routine Eye Exam | (1 every year) |
| Eyeglasses or Contact Lenses after Cataract Surgery | You pay nothing |
| Routine Eyewear | Our plan pays up to $400 every year for supplemental eyewear from any in-network Superior Vision provider. |
| Dental | |
| Medicare-covered Dental Services | $0 copay |
| Preventive Dental Services | Cleaning(s) (2 cleanings per year): Oral exam(s) (Frequency determiend by type of oral exam): $0 copay |
| Fluoride Treatments | Fluoride treatments (2 fluoride treatments per year): |
| Comprehensive Dental Services | The plan has a maximum coverage amount of $1,500 per year for in-network non-Medicare-covered comprehensive dental services. Members are responsible for the difference between the allowed amount and the billed amount for any out-of-network services. |
| Optional Supplemental Benefits | Not Available |
| Restorative services (such as inlays, onlays, crowns, resin restoration, etc.) | $0 copay |
| Endodontics | $0 copay |
| Periodontics | $0 copay |
| Extractions | $0 copay |
| Prosthodontics/Other oral/maxillofacial surgery/Other services (such as removable complete and partial dentures, repair or replace teeth in dentures, removal of exostosis, anesthesia, etc.) | Frequency dependent on procedure. |
| Documents | |
2025 Plans
Johns Hopkins Advantage MD (HMO) has an in-network out-of-pocket maximum of $7,550. Johns Hopkins Advantage MD Tribute (HMO) has an in-network out-of-pocket maximum of $6,800. Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO), Johns Hopkins Advantage MD Primary (PPO) have an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD D-SNP (HMO) has an in-network out-of-pocket maximum of $8,850.
For out-of-network benefits, you pay a percentage for most covered services.
Limitations: 1. Members are responsible for the difference between the allowed amount and the billed amount. For more information, please review the Evidence of Coverage. 2. The comprehensive dental benefit for the Optional Supplement benefits for the Johns Hopkins Advantage MD (HMO) and Johns Hopkins Advantage MD Plus (PPO) plan has a $1,000 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD Tribute (HMO) and Johns Hopkins Advantage MD Primary (PPO) plan has a $2,000 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD (PPO) plan has a $1,000 Annual Maximum.The comprehensive dental benefit for the Johns Hopkins Advantage MD D-SNP (HMO) plan has a $2,500 Annual Maximum.
Prior authorizations are required for the following: endodontics, general anesthesia when medically necessary and administered in connection with oral or dental surgery, oral surgery, periodontics, bridges, crowns, inlays, onlays, and dentures (full or partial).