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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 | $225 copay |
| Emergency Care | $110 copay |
| Worldwide Emergency & Urgently Needed Services | 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 | Medicare-covered chiropractic care: |
| Hearing Aid Services | $0 copay (hearing exam) Hearing aids: |
| Silver&Fit® Program | You pay nothing at participating fitness centers. |
| Prescription | |
| Pharmacy Deductible | $590 |
| Preferred Generic (Tier 1) | $0 for a one-month supply |
| Generic (Tier 2) | $10 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 | You pay nothing |
| Eyeglasses or Contact Lenses after Cataract Surgery | You pay nothing |
| Routine Eyewear | Our plan pays up to $250 every year for supplemental eyewear from any in-network Superior Vision provider. |
| Dental | |
| Medicare-covered Dental Services | 20% coinsurance |
| Preventive Dental Services | Cleaning(s) (1 cleaning per year): $20 copay Oral exam(s) (Frequency determined by type of oral exam): $20 copay |
| Fluoride Treatments | Not covered |
| Comprehensive Dental Services | Not covered |
| Optional Supplemental Benefits | $25 monthly premium (Frequency dependent on procedure) The plan has a maximum coverage amount of $1,000 per year for in-and out-of-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. |
| Restorative services (such as inlays, onlays, crowns, resin restoration, etc.) | Frequency dependent on procedure. |
| Endodontics | Frequency dependent on procedure. |
| Periodontics | Frequency dependent on procedure. |
| Extractions | Frequency dependent on procedure. |
| 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 | |
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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).