Page 68 - Cover letter and evaluation for Thomas Barr

10/14/2017 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 21012
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 0585196480
and more coverage and star ratings.
Password Date: 10/14/2017
Important Coverage Information

You are now viewing 2018 plan data. View 2017 plan data.
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A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Johns Hopkins Advantage P.O. Box 3538 Overall Star Rating: [?] Enrollment begins
Scranton, PA 18505 October 15, 2017
MD (PPO)
(H3890-001-0) Members: 2.5 out of 5 stars
1-877-293-5325
Organization: Johns Hopkins 711 (TTY/TDD)
HealthCare
Non Members:
Plan Type: 1-888-403-7682
711 (TTY/TDD)

Benefits Highlights

Monthly health plan premium $5.70
Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $10,000 In and Out-of-network
responsibility (does not include $6,700 In-network
prescription drugs)
Optional supplemental benefits [?] Yes

Inpatient hospital coverage
In-Network: $285 for days 1 through 7
$0 for days 8 through 90
$0 for days 91 and beyond
Out-of-Network: 30% per stay

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