Ppo Copay



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.

  • Summary of Benefits – English | Spanish

Switch between Advantage MD Plans* and Original Medicare

Copay plans include: Copays – for basic services like preventive exams, telemedicine and pharmacy Virtual visits with board-certified doctors – 24/7, with Doctor On Demand Go365® rewards for healthy behaviors – like Target and Amazon gift cards. Copay – a fixed dollar amount you must pay to a provider at the time services are received. Out-of-Pocket Max – the maximum amount you pay each calendar year to receive covered services after you meet your deductible. Once you meet your out-of-pocket maximum, the Plan pays 100% of covered services you receive.

Advantage MD Plans
Plans & Monthly Plan Premium
Plans & Monthly Plan Premium

Johns Hopkins
ADVANTAGE MD (HMO)

$40 / month

plus Part B premium


Johns Hopkins ADVANTAGE MD (HMO) for Baltimore City residents

$20 / month

Johns Hopkins
ADVANTAGE MD (PPO) - not available in Montgomery County

$91 / month

Johns Hopkins
ADVANTAGE MD PLUS (PPO) - not available in Montgomery County

$121 / month

Johns Hopkins
ADVANTAGE MD PREMIER (PPO) for Montgomery County residents only

$351 / month

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
ReferralsRequired for Specialist Visits onlyNot requiredNot requiredNot required
Urgent Care
Urgent Care$40 copay
The copay is not waived if you are admitted to the
hospital.		$40 copay.
The copay is not waived if you are admitted to the hospital.		$40 copay
The copay is not waived if you are admitted to the
hospital.		$20 copay
The copay is not waived if you are admitted to the
hospital.
Telemedicine
Telemedicine$5 copay for PCP visits
$50 copay for specialists and other office visits
$40 copay for urgent care visits		$10 copay for PCP visits
$50 copay for specialists and other office visits
$40 copay for urgent care visits		$5 copay for PCP visits
$50 copay for specialists and other office visits
$40 copay for urgent care visits		$0 copay for PCP visits
$10 copay for specialists and other office visits
$20 copay for urgent care visits
Ambulatory Surgical Centers Outpatient Surgery
Ambulatory Surgical Centers Outpatient Surgery$225 copay$225 copay$225 copay$50 copay
Emergency Care
Emergency Care$90 copay
The copay is waived if
you are admitted to the
hospital within 24 hours
for the same condition. 		$90 copay
The copay is waived if
you are admitted to the
hospital within 24 hours
for the same condition. 		$90 copay
The copay is waived if
you are admitted to the
hospital within 24 hours
for the same condition. 		$90 copay
The copay is waived if
you are admitted to the
hospital within 24 hours
for the same condition.
Worldwide Emergency & Urgently Needed Services
Worldwide Emergency & Urgently Needed ServicesNot coveredNot covered$90 copayment for Emergency Care and $40 copayment for Urgently Needed Services$90 copayment for Emergency Care and $20 copayment for Urgently Needed Services
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$50 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 Services20% 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
Acupuncture20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain. $200 supplemental benefit for any injury or illness.20% coinsurance (up to 12 visits within 90 days) for chronic lower back pain. $300 supplemental benefit for any injury or illness.
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 MoreAvailable 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.Comprehensive dental and fitness benefits included at no additional cost.
Routine Chiropractic Services
Routine Chiropractic ServicesNot coveredNot 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 MoreTwo options available through TruHearing (up to two per year); copay from $699 per aidTwo options available through TruHearing (up to two per year); copay from $699 per aidTwo options available through TruHearing (up to two per year); copay from $699 per aidTwo options available through TruHearing (up to two per year); copay from $399 per aid
Silver&Fit® Program Learn More
Silver&Fit® Program Learn MoreIncluded in optional supplemental benefits for an additional premiumIncluded in optional supplemental benefits for an additional premiumIncludedIncluded
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 Tier33% of the cost26% of the cost26% of the cost33% of the cost
Mail Order
Mail OrderAvailableAvailableAvailableAvailable
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$200 copay$200 copay$200 copay50% coinsurance
Oral Surgery
Oral Surgery$50 copay$50 copay$50 copay20% coinsurance
Oral Pathology Biopsy
Oral Pathology Biopsy$50 copay$50 copay$50 copay50% coinsurance
Periodontics
Periodontics$50 copay$50 copay$50 copay50% coinsurance
Restorative Fillings
Restorative Fillings$50 copay$50 copay$50 copay20% 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 copay50% 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 copay50% 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 copay50% coinsurance
Bridges Replacement
(due to structural changes in the mouth)
Bridges Replacement
(due to structural changes in the mouth)		$400 copay$400 copay$400 copay50% coinsurance
Crowns, Inlays and Onlays Installation
Crowns, Inlays and Onlays Installation$400 copay$400 copay$400 copay50% 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 copay50% coinsurance
Crowns, Inlays and Onlays Replacement
Crowns, Inlays and Onlays Replacement$400 copay$400 copay$400 copay50% 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 copay50% 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 copay50% 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 copay50% 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 $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD Plus (PPO) has 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 Premier (PPO) has 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 (HMO) has an in-network out-of-pocket maximum of $7,550.

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).

2020 Optional Supplemental Benefits
Plans & Additional Monthly Plan Premium
Plans & Additional Monthly Plan Premium

Johns Hopkins
ADVANTAGE MD (HMO)

$30 / month

Optional Supplemental Benefits include comprehensive dental benefits through DentaQuest and fitness benefits through the Silver&Fit Exercise and Healthy Aging Program. This is a combined package and cannot be purchased separately.

Johns Hopkins
ADVANTAGE MD (PPO) - not available in Montgomery County

$30 / month

Optional Supplemental Benefits include comprehensive dental benefits through DentaQuest and fitness benefits through the Silver&Fit Exercise and Healthy Aging Program. This is a combined package and cannot be purchased separately.

Johns Hopkins
ADVANTAGE MD PLUS (PPO) - not available in Montgomery County

$28 / month

Optional Supplemental Benefits include comprehensive dental benefits through DentaQuest. The Silver&Fit Exercise and Healthy Aging Program fitness benefit is included in the PPO Plus plan, for no additional premium.

Johns Hopkins
ADVANTAGE MD PREMIER (PPO) for Montgomery County residents

Included at no additional cost

Comprehensive dental benefits through DentaQuest and the Silver&Fit Exercise and Healthy Aging Program fitness benefit are included in the PPO Premier plan, for no additional premium.

Fitness Benefit
Silver&Fit® Exercise and Healthy Aging Program
Silver&Fit® Exercise and Healthy Aging ProgramWith the Silver&Fit program, you can either choose a fitness center or the Silver&Fit Home Fitness Program.
Learn More		With the Silver&Fit program, you can either choose a fitness center or the Silver&Fit Home Fitness Program.
Learn More		Included in PPO Plus Plan for no addition premiumIncluded in PPO Premier Plan for no addition premium
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$200 copay$200 copay$200 copay50% coinsurance
Oral Surgery
Oral Surgery$50 copay$50 copay$50 copay20% coinsurance
Oral Pathology Biopsy
Oral Pathology Biopsy$50 copay$50 copay$50 copay50% coinsurance
Periodontics
Periodontics$50 copay$50 copay$50 copay50% coinsurance
Restorative Fillings
Restorative Fillings$50 copay$50 copay$50 copay20% 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 copay50% 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 copay50% 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 copay50% coinsurance
Bridges Replacement
(due to structural changes in the mouth)
Bridges Replacement
(due to structural changes in the mouth)		$400 copay$400 copay$400 copay50% coinsurance
Crowns, Inlays and Onlays Installation
Crowns, Inlays and Onlays Installation$400 copay$400 copay$400 copay50% 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 copay50% coinsurance
Crowns, Inlays and Onlays Replacement
Crowns, Inlays and Onlays Replacement$400 copay$400 copay$400 copay50% 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 copay50% 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 copay50% 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 copay50% coinsurance

*Please note: this information does not apply to Advantage MD Group.

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).

View our 2019 optional supplemental benefits brochure.
2020 Original Medicare Plan
Plans & Monthly Plan Premium
Plans & Monthly Plan Premium

ORIGINAL MEDICARE
Part A/Part B

MEDICAL BENEFITS (partial listing: in-network)
MEDICAL BENEFITS (partial listing: in-network)
Medical Deductible
Medical DeductiblePrimary Care Provider Visit
Primary Care Provider VisitSpecialist Visit
Specialist VisitReferrals
ReferralsUrgent Care
Urgent CareOutpatient Surgery, ASC
Outpatient Surgery, ASCEmergency Care
Emergency CareInpatient Hospital Stay
Inpatient Hospital StayAnnual Routine Vision Exam
Annual Routine Vision ExamDiagnostic Dental Services Learn More
Diagnostic Dental Services Learn MoreSupplemental Dental
Supplemental DentalChiropractic Care
Chiropractic CareHearing Aid Services
Hearing Aid ServicesSilver&Fit® Program
Silver&Fit® Program PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy)
PRESCRIPTION DRUG BENEFITS (30-day supply; in-network pharmacy)
Deductible
DeductiblePreferred Generic
Preferred GenericGeneric
GenericPreferred Brand
Preferred BrandNon-Preferred Drug
Non-Preferred DrugSpecialty Tier
Specialty TierMail Order
Mail OrderJohns Hopkins OnDemand Virtual Care
Expand

Get care anytime, anywhere with Johns Hopkins OnDemand Virtual Care. Connect through your mobile device or computer for a video visit with a health care provider 24/7, from anywhere in the United States. Johns Hopkins OnDemand Virtual Care has providers ready to care for you at any time, no appointment needed. A health care provider is available within minutes to review symptoms and prescribe medications, as necessary.

Common uses for this service include minor care concerns, such as:

  • Cold and flu symptoms
  • Rashes
  • Allergies
  • Sinus problems
  • Pinkeye
Copay

This service is available to all Advantage MD plan members.

Get connected with a provider now or learn more.

Do not use Johns Hopkins OnDemand Virtual Care for emergency medical matters.
Call 911 if you are experiencing a medical emergency.

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Johns Hopkins Advantage MD covers up to two hearing aids per year when purchased through TruHearing.

Features for 2021

Aetna Copay Amounts

  • 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 $50 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

  1. Call us and ask for TruHearing. PPO members: call 1-877-293-5325 (TTY: 711); HMO members: call 1-877-293-4998 (TTY: 711).
  2. 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.
  3. If hearing loss is discovered, your audiologist or hearing instrument specialist will help you choose the right hearing aids and order them through TruHearing.
  4. 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 Program
Expand

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 have access to the following enrollment options:

  • Work out at a participating fitness center. Enjoy all of the standard amenities* of the fitness center including cardiovascular and strength training equipment, and;
  • Work out at home. You can order up to two home fitness kits per benefit year through the Home Fitness program. Choose from a selection of 34 home fitness kits including: yoga, Chair Pilates, Tai Chi, Cardio Strength, and many others.

Bcbs Ppo Copay

You also have access to the following Silver&Fit® program features:

Hmo Vs Ppo Copay

  • 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!™ tool – 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 a wearable fitness tracker or app may be required to use the Connected! tool and is not reimbursable by the Silver&Fit program.

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. Kits are subject to change. Participating facilities and fitness chains may vary by location and are subject to change.