Tribute (HMO)

Plan Overview

$0 / month

Medical Deductible

This plan does not have any medical deductibles.

Pharmacy Deductible

Part D benefits are not offered with this plan.

Coverage Details

Medical

Medical Deductible	This plan does not have any medical deductibles.
Primary Care Provider Visit	$0 copay
Specialist Visit	$50 copay
Referrals	Required for Specialist Visits only.
Urgent Care	$40 copay The copay is not waived if you are admitted to the hospital.
Telehealth	$0 copay
Ambulatory Surgical Centers Outpatient Surgery	$250 copay
Emergency Care	$110 copay The copay is waived if you are admitted to the hospital within 24 hours for the same condition.
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	Medicare-covered podiatry care: $50 copay Non-Medicare covered podiatry care: Not covered
Acupuncture	Medicare-covered acupuncture: 20% coinsurance
Routine Chiropractic Services	Medicare-covered chiropractic care: $10 copay Non-Medicare covered chiropractic care: Not covered
Hearing Aid Services Learn more	$0 copay (hearing exam) You pay a $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).
Silver&Fit® Program Learn more	You pay nothing at participating fitness centers.
Prescription
Pharmacy Deductible	Part D benefits are not offered with this plan.
Mail Order	Part D benefits are not offered with this plan.
Preferred Generic (Tier 1)	Part D benefits are not offered with this plan.
Generic (Tier 2)	Part D benefits are not offered with this plan.
Preferred Brand (Tier 3)	Part D benefits are not offered with this plan.
Non-Preferred Drug (Tier 4)	Part D benefits are not offered with this plan.
Specialty Tier (Tier 5)	Part D benefits are not offered with this plan.
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): You pay nothing
Eyeglasses or Contact Lenses after Cataract Surgery	You pay nothing
Routine Eyewear	Our plan pays up to $300 every two years for supplemental eyewear from any in-network Superior Vision provider.
Dental
Medicare-covered Dental Services	$0 copay
Preventive Dental Services	(2 cleanings per year): $0 copay Oral exam(s) (Frequency determined by type of oral exam): $0 copay
Fluoride Treatments	(2 fluoride treatments per year): $0 copay
Comprehensive Dental Services	(Frequency dependent on procedure.) The plan has a maximum coverage amount of $2,000 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.)	Frequency dependent on procedure. In-network: $0 copay
Endodontics	Frequency dependent on procedure. In-network: $0 copay
Periodontics	Frequency dependent on procedure. In-network: $0 copay
Extractions	Frequency dependent on procedure. In-network: $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. In-network: $0 copay
Documents
Summary of Benefits (PPO & HMO) Evidence of Coverage (HMO Tribute) Annual Notice of Changes (HMO) HMO LIS Premium Summary Chart – English \| Spanish Pre-Enrollment Checklist – English \| Spanish

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).

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Tribute (HMO)

Plan Overview

Coverage Details

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