Page 46 - Cover letter and evaluation for Michele Buros

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Zip Code: 15146
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs
and more coverage and star ratings. Drug List ID: 2133754848
Password Date: 02/21/2018
Important Coverage Information

Symbols
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 Vision Coverage Some Hearing Coverage
* Estimated

Advantra Silver (PPO) PO Box 7087 Overall Star Rating: [?] Enroll
London, KY 40742
(H5522-018-0)
4 out of 5 stars
Members:
Organization: HealthAmerica 1-800-290-0190
Plan Type: Local Preferred 711 (TTY/TDD)
Provider Organization
Non Members:
1-855-338-9566
711 (TTY/TDD)

Benefits Highlights
Monthly health plan premium $14.00

Health plan deductible $1,000 annual deductible

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 [?] No
Inpatient hospital coverage
In-Network: $335 per stay
Out-of-Network: 40% per stay

Outpatient hospital coverage
In-Network: $220 per visit
Out-of-Network: 40% per visit

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