Understand Your Benefits
Looking for 2019 plan benefits?
With so many benefits, it’s important to understand your Advantage MD coverage to get the most out of your health care. Use the chart below to see your benefits at-a-glance.
For specific information on your benefits, use our interactive tool to browse your covered benefits. You can also download a PDF of your plan’s summary of benefits.
Switch between Advantage MD Plans* and Original Medicare
| Advantage MD Plans | ||||
|---|---|---|---|---|
| Plans & Monthly Plan Premium | ||||
| Plans & Monthly Plan Premium | Johns Hopkins | Johns Hopkins | Johns Hopkins | Johns Hopkins |
| MEDICAL BENEFITS (partial listing: in-network) | ||||
| MEDICAL BENEFITS (partial listing: in-network) | ||||
| Medical Deductible | ||||
| Medical Deductible | $0 | $0 | $0 | $0 |
| Primary Care Provider Visit | ||||
| Primary Care Provider Visit | $5 copay | $10 copay | $5 copay | $0 copay |
| Specialist Visit | ||||
| Specialist Visit | $50 copay | $50 copay | $50 copay | $10 copay |
| Referrals | ||||
| Referrals | Required for Specialist Visits only | Not required | Not required | Not required |
| Urgent Care | ||||
| Urgent Care | $40 copay | $40 copay | $40 copay | $20 copay |
| Ambulatory Surgical Centers Outpatient Surgery | ||||
| Ambulatory Surgical Centers Outpatient Surgery | $250 copay | $250 copay | $250 copay | $50 copay |
| Emergency Care | ||||
| Emergency Care | $90 copay | $90 copay | $90 copay | $50 copay |
| Worldwide Emergency & Urgently Needed Services | ||||
| Worldwide Emergency & Urgently Needed Services | Not covered | Not covered | $90 copayment for Emergency Care and $40 copayment for Urgently Needed Services (up to $50,000 combined limit per year outside of U.S.) | $0 copay for Emergency Care or Urgently Needed Services (up to $50,000 combined limit per year outside of U.S.) |
| Inpatient Hospital Stay | ||||
| Inpatient Hospital Stay | $310/day copay for days 1-5; $0 copay for days 6-90; Medicare allows 60 "lifetime reserve" days | $310/day copay for days 1-6; $0 copay for days 7-90; Medicare allows 60 "lifetime reserve" days | $310/day copay for days 1-6; $0 copay for days 7-90; Medicare allows 60 "lifetime reserve" days | $200 copay per admission (90 days); Medicare allows 60 "lifetime reserve" days |
| Vision benefits | ||||
| Vision benefits | $0 copay once per year; up to $150 allowance for additional eyewear every two years | $0 copay once per year; no additional eyewear coverage | $0 copay once per year; up to $150 allowance for additional eyewear every two years | $0 copay once per year; up to $300 allowance for additional eyewear every two years |
| Routine Podiatry Services | ||||
| Routine Podiatry Services | 20% coinsurance (up to 8 times per year) | 20% coinsurance (up to 6 times per year) | 20% coinsurance (up to 6 times per year) | $10 copay (up to 12 times per year) |
| Acupuncture | ||||
| Acupuncture | Not covered | Not covered | $200 annual allowance | $300 annual allowance |
| Preventive Dental Services | ||||
| Preventive Dental Services | $15 copay (cleaning); $15 copay (oral exam); $25 copay (dental x-ray) Frequency depends on type of service | $15 copay (cleaning); $15 copay (oral exam); $25 copay (dental x-ray) Frequency depends on type of service | $10 copay (cleaning); $10 copay (oral exam); $20 copay (dental x-ray) Frequency depends on type of service | $0 copay (cleaning); $0 copay (oral exam); $0 copay (dental x-ray); $0 copay (Fluoride treatment) Frequency depends on type of service |
| Optional Supplemental Benefits Learn More | ||||
| Optional Supplemental Benefits Learn More | Available for an extra premium ($30) for comprehensive dental and fitness. | Available for an extra premium ($30) for comprehensive dental and fitness. | Available for an extra premium ($28) for comprehensive dental. | Not Available Comprehensive dental and fitness benefits included at no additional cost. |
| Routine Chiropractic Services | ||||
| Routine Chiropractic Services | Not covered | Not covered | $20 copay (up to 12 times per year) | $10 copay (up to 12 times per year) |
| Hearing Aid Services Learn More | ||||
| Hearing Aid Services Learn More | Two options available through TruHearing (up to two per year); copay from $699 per aid | Two options available through TruHearing (up to two per year); copay from $699 per aid | Two options available through TruHearing (up to two per year); copay from $699 per aid | Two options available through TruHearing (up to two per year); copay from $399 per aid |
| Silver&Fit® Program Learn More | ||||
| Silver&Fit® Program Learn More | Included in optional supplemental benefits for an additional premium | Included in optional supplemental benefits for an additional premium | Included | Included |
| PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy) | ||||
| PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy) | ||||
| Deductible | ||||
| Deductible | $0 | $350 deductible (applicable to tiers 3, 4, and 5) | $350 deductible (applicable to tiers 3, 4, and 5) | $0 |
| Preferred Generic | ||||
| Preferred Generic | $0 copay | $7 copay | $4 copay | $3 copay |
| Generic | ||||
| Generic | $10 copay | $15 copay | $12 copay | $10 copay |
| Preferred Brand | ||||
| Preferred Brand | $47 copay | $47 copay | $47 copay | $40 copay |
| Non-Preferred Drug | ||||
| Non-Preferred Drug | $100 copay | $100 copay | $100 copay | $90 copay |
| Specialty Tier | ||||
| Specialty Tier | 33% of the cost | 26% of the cost | 26% of the cost | 33% of the cost |
| Mail Order | ||||
| Mail Order | Available | Available | Available | Available |
| Comprehensive Dental Benefits | ||||
|---|---|---|---|---|
| BASIC RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| BASIC RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| Endodontics | ||||
| Endodontics | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Oral Surgery | ||||
| Oral Surgery | $50 copay | $50 copay | $50 copay | 20% coinsurance |
| Oral Pathology Biopsy | ||||
| Oral Pathology Biopsy | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Periodontics | ||||
| Periodontics | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Restorative Fillings | ||||
| Restorative Fillings | $50 copay | $50 copay | $50 copay | 20% coinsurance |
| General Anesthesia (when medically necessary and administered in connection with oral or dental surgery) | ||||
| General Anesthesia (when medically necessary and administered in connection with oral or dental surgery) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| MAJOR RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| MAJOR RESTORATIVE (in-network) *out-of-network cost may be higher | ||||
| Bridges Installation or Addition (due to the covered extraction of one or more natural teeth) | ||||
| Bridges Installation or Addition (due to the covered extraction of one or more natural teeth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Bridges Adjustment or Repair (due to the covered extraction of one or more natural teeth) | ||||
| Bridges Adjustment or Repair (due to the covered extraction of one or more natural teeth) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Bridges Replacement (due to structural changes in the mouth) | ||||
| Bridges Replacement (due to structural changes in the mouth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Installation | ||||
| Crowns, Inlays and Onlays Installation | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Adjustment or Repair (more than six months after installation) | ||||
| Crowns, Inlays and Onlays Adjustment or Repair (more than six months after installation) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Crowns, Inlays and Onlays Replacement | ||||
| Crowns, Inlays and Onlays Replacement | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Dentures (full or partial) Installation or Addition (due to the covered extraction of one or more natural teeth) | ||||
| Dentures (full or partial) Installation or Addition (due to the covered extraction of one or more natural teeth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
| Dentures (full or partial) Adjustment or Repair (more than six months after installation) | ||||
| Dentures (full or partial) Adjustment or Repair (more than six months after installation) | $50 copay | $50 copay | $50 copay | 50% coinsurance |
| Dentures (full or partial) Replacement of Full Denture (due to structural changes in the mouth) | ||||
| Dentures (full or partial) Replacement of Full Denture (due to structural changes in the mouth) | $400 copay | $400 copay | $400 copay | 50% coinsurance |
*Please note: this information does not apply to Advantage MD Group.
Johns Hopkins Advantage MD (PPO) has an in-network out-of-pocket maximum of $6,700 and a combined in- and out-of-network maximum of $10,000. Johns Hopkins Advantage MD Plus (PPO) has an in-network out-of-pocket maximum of $6,700 and a combined in- and out-of-network maximum of $10,000. Johns Hopkins Advantage MD Premier (PPO) has an in-network out-of-pocket maximum of $1,500 and a combined in- and out-of-network maximum of $5,000. Johns Hopkins Advantage MD (HMO) has an in-network out-of-pocket maximum of $6,700.
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) plan, Johns Hopkins Advantage MD (PPO) plan, and Johns Hopkins Advantage MD Plus (PPO) plan has a $1,200 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD Premier (PPO) plan has a $1,500 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).
Our Service AreaCollapse
Advantage MD offers plans for Medicare-eligible residents in 12 counties including Baltimore City. See the map below for our service area.
The Johns Hopkins Advantage MD (HMO) service area includes the following counties in Maryland: Anne Arundel, Baltimore, Baltimore City, Calvert, Carroll, Frederick, Howard, Montgomery, Somerset, Washington, Wicomico, and Worcester.
The Johns Hopkins Advantage MD (PPO) and Johns Hopkins Advantage MD Plus (PPO) service area include the following counties in Maryland: Anne Arundel, Baltimore, Baltimore City, Calvert, Carroll, Frederick, Howard, Somerset, Washington, Wicomico, and Worcester. (Not available in Montgomery County.)
The Johns Hopkins Advantage MD Premier (PPO) service area includes Montgomery County only.
Going Out-of-NetworkCollapse
As a member of our PPO, Plus PPO or Premier PPO plan, you can choose to receive care from out-of-network providers. These plans will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. For more information about cost-sharing for out-of-network providers, please refer to the Medical Benefits chart in Chapter 4 of your plan’s EOC.
As a member of our HMO plan, you must use in-network providers to get your medical care and services. Care you receive from an out-of-network provider will not be covered. The only exceptions are emergencies, urgently needed services in which the network is not available (generally, when you are out of the area), out-of-area dialysis, and in cases in which Johns Hopkins Advantage MD (HMO) authorizes use of out of network providers. For more information about the network, please refer to Chapter 3 of your plan’s EOC.
Explanation of Hearing Aid CoverageCollapse
Johns Hopkins Advantage MD covers up to two hearing aids per year when purchased through TruHearing.
New Features for 2020
- Additional channels and programs for a more customized listening experience.
- State-of-the-art technology that helps you hear speech even in noisy environments.
- Own Voice Processing (OVP) for a more natural sound to your own voice.
- Smartphone-compatible directly to iPhone, iPad, and iPod Touch devices so you can stream audio and phone calls directly to your ears (connectivity is also available to many Android phones with use of a phone clip accessory.)
- Rechargeable battery upgrade option on the TruHearing Premium RIC Li, Slim RIC Li, Standard BTI Li, and CROS Li styles for an additional $75 per aid.
Coverage includes*
- 2 hearing aids per year when purchased through TruHearing
- 3 follow-up visits with an in-network provider for fitting and adjustment of hearing aids
- 45-day trial
- 3-year manufacturer warranty for repairs and one-time loss and damage replacement
- 48 batteries per aid included with non-rechargeable models
How to Get Hearing Aids
- Call us and ask for TruHearing. PPO members: call 1-877-293-5325 (TTY: 711); HMO members: call 1-877-293-4998 (TTY: 711).
- A TruHearing hearing consultant will verify your coverage and help you set up a hearing exam with an audiologist or hearing instrument specialist in your area.
- If hearing loss is discovered, your audiologist or hearing instrument specialist will help you choose the right hearing aids and order them through TruHearing.
- When the hearing aids arrive, you’ll return to have them fitted and programmed by your audiologist or hearing instrument specialist.
*Three follow-up visits must be used within one year after the date of initial purchase. Forty-five-day trial and hearing aid returns, repairs, and replacements subject to provider and manufacturer fees. For questions regarding fees, contact TruHearing customer service at 1-800-334-1807 (TTY: 711).
The Silver&Fit® Exercise and Healthy Aging ProgramCollapse
The Silver&Fit® program is designed for older adults and is provided at no additional cost for members who choose the Advantage MD Plus plan. With this program, you can choose from the following enrollment options:
- Work out at a participating fitness facility. Enjoy all of the standard amenities* of the fitness facility including cardiovascular and strength training equipment.
- Work out at home. If you choose the Home Fitness program, you can order up to two home fitness kits per benefit year. Choose from a selection of kits including: yoga, Chair Pilates, tai chi, cardio strength, and many others.
You also have access to the following Silver&Fit® program features:
- Healthy Aging education classes (online or have DVDs mailed to you)
- The Silver Slate® – Stay up-to-date on fitness, nutrition, and weight management with our newsletter
- The Silver&Fit Connected!™ Program – a fun and easy way to track exercise at a facility or through a wearable fitness device**
- Earn Rewards** for tracking your activity
*Services that require an additional cost are not included.
**Rewards subject to change; purchase of device or app is not included.
Learn more and see what fitness facilities participate by going to www.silverandfit.com.
The Silver&Fit® program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit®, Silver&Fit Connected!™ and The Silver Slate® are trademarks of ASH and used with permission herein. All programs and services are not available in all areas.
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