2022 MyTruAdvantage Choice (PPO)

The MyTruAdvantage Choice (PPO) plan offers a low monthly premium and copay, along with the option to see providers outside of the MyTruAdvantage network. It also includes out-of-state travel coverage. With the MyTruAdvantage Choice (PPO), you get an affordable and flexible plan, plus all the extras you can count on.

Benefits

Annual Deductible

In-networkOut-of-network
$0$0

The amount you pay for covered health care services before MyTruAdvantage starts to pay. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services.

Out-of-Pocket Maximum

In-networkIn and Out-of-network
$5000$10000

The highest yearly amount you will have to pay out-of-pocket for covered healthcare services. Your coinsurance or copays count towards the maximum out-of-pocket; premiums and prescription costs do not.

Inpatient Hospital Care

In-networkOut-of-network
$350
40%
Each day, days 1-5Each stay

$0

 

Each day, days 6 and beyond

There is no limit to the number of days covered by the plan each hospital stay.

Outpatient Hospital Care

In-networkOut-of-network
$225$375

Each visitEach visit

Includes Ambulatory surgical center, Outpatient hospital and Observation.

Doctor Visits

In-networkOut-of-network
$5
$40
Each primary care physician (PCP) visitEach primary care physician (PCP) visit

$35
$55
Each specialist visitEach specialist visit

Emergency Care and Urgently needed services section wherever you are in the United States or all over the world.

Preventive Care

In and out-of-network
$0

Each service

Includes immunizations, physical exams (initial exam and annual wellness visit), colorectal screening, pap smears and pelvic exams screening, prostate cancer screening, bone mass measurement, mammography screening, and outpatient hospital services - preventive.

Emergency & Urgent Care

In-networkOut-of-network
$90
$90
Each emergency room visitEach emergency room visit

$50
$50
Each urgent care visitEach urgent care visit

Complex Radiology/Imaging

In-networkOut-of-network
$26040%

Each serviceEach service

This includes what you pay for radiology/imaging services such as a CT scan or MRI

General Radiology/Imaging

In-networkOut-of-network
$6040%

Each serviceEach service

Tests/Procedures

In-networkOut-of-network
$15$15

Each serviceEach service

Lab Services

In-networkOut-of-network
$15$15

Each serviceEach service

Outpatient X-rays

In-networkOut-of-network
$30$40

Each serviceEach service

Radiation Therapy

In-networkOut-of-network
$6040%

Each serviceEach service

Medicare-Covered Hearing Exam

In-networkOut-of-network
$0 - $35$55

Each visitEach visit

Routine Hearing Exam

In and out-of-network
$0

Up to one per year

Routine hearing services must be provided by a TruHearing provider.

Hearing Aid

In and out-of-network
$699 and $999

Depending on the type

Medicare-Covered Dental

In and out-of-network
20%

Of all Medicare-covered dental services

Preventive (Routine) Dental

$0$0$0

Two cleanings per yearTwo exams per yearOne set of bitewing x-rays per year

There is a buy-up option with additional coverage for an additional premium. Please see Optional Benefits section for more information.

Medicare-Covered Vision Exam

In-networkOut-of-network
$0$40

Each examEach exam

Routine Vision Exam

In-networkOut-of-network
$0$40

Each examEach exam

Glasses/Contacts

In-networkOut-of-network
$15050%, up to $150

Annual benefit amountAnnual benefit amount

Mental Health Care - Inpatient Visit

In-networkOut-of-network
$350 / $040%

Days 1 - 5 / 6 - 90Each stay

Outpatient Group Therapy

In-networkOut-of-network
$30$40

Each visitEach visit

Outpatient Individual Therapy

In-networkOut-of-network
$30$40

Each visitEach visit

Skilled Nursing Facility

In-networkOut-of-network
$0 / $188$175

Each day, Days 1-20 / Days 21-100Each day, days 1 - 58

Physical Therapy

In-networkOut-of-network
$40$55

Each visitEach visit

Ambulance

In and out-of-network
$260 / $325

Each trip, Ground/Air

Transportation

Not covered

Over-the-Counter (OTC) Card

In and out-of-network
$45

Every 3 months

The OTC benefit offers you an easy way to get generic over-the-counter health and wellness products by phone at 1-888-628-2770 (TTY: 711) or online at www.cvs.com/otchs/MyTruAdvantage. You order from a list of approved OTC items, and OTC Health Solutions will mail them directly to your home address.

Fitness Benefit

In and out-of-network
$0

Includes a no-cost gym membership at a participating fitness center or YMCA, one Stay Fit Kit (options include a Fitbit, Garmin, yoga, or strength kit), and 2 home fitness kits, where you can choose from 34 options like Aqua, Tai Chi, Chair-based exercise and more.


Prescription Drug Benefits - Part B

Medicare Part B Drugs may require prior authorization. The copay for chemotherapy drugs and other Part B drugs is 20%. Step Therapy may be required for certain Part B drugs (see Chapter 4 section 2.1 "Medicare Part B Drugs" of the EOC at www.MyTruAdvantage.com/Members for more details).

Prescription Drug Benefits - Part D

The below tables are broken out by preferred pharmacy, standard pharmacy and mail order. Please see the Pharmacy list to see what pharmacies are in which category.

Download the Pharmacy List

Annual Deductible

Tiers 1-2Tiers 3, 4, and 5
$0$100

Tier 1 (Preferred Generic), Tier 2 (Generic), Tier 3 (Preferred Brand), Tier 4 (Non-Preferred Drug), Tier 5 (Specialty Tier)

Initial Coverage

You pay the following until your total yearly drug costs reach $4430. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. Once you reach that amount, you will enter the Coverage Gap. You may get your drugs at network retail pharmacies and mail order pharmacies. During this stage, your out-of-pocket costs for Select Insulins will be $35 for a one-month (30-day) supply.

Tier 1 (Preferred Generic)

$2$0$7

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 2 (Generic)

$8$0$14

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 3 (Preferred Brand)

$42$141$47

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 4 (Non-preferred Drug)

$95$300$100

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 5 (Specialty)

31% of cost   Not Covered

Preferred & Standard retail (30-day)Mail order (90-day)
31% of costNot Covered 31% of cost

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Coverage Gap

When you reach your total yearly drug cost (which includes what our plan has paid and what you have paid) of $4430, you will enter what is called a coverage gap. At this time, you will pay 25% of the plan's cost for covered generic drugs and 25% of the plan's cost for covered brand drugs, plus a dispensing fee, until your total costs reach $7050. Most Medicare plans have this coverage gap (also called the "donut hole"), but not everyone will enter the coverage gap. During this stage, your out-of-pocket costs for Select Insulins will be $35 for a one-month (30-day) supply.

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7050, you pay the greater of: 5% of the cost, or $3.95 copay for generic (including brand drugs treated as generic) and a $9.85 copay for all other drugs.

Optional Benefits

Enhanced Dental Package for MyTruAdvantage Choice (PPO)

In and out-of-network
$32.70

Monthly premium

$0 for each service: Emergency palliative treatment, fluoride treatment, brush biopsy, and other basic ser­vices such as films, tests, and anesthesia. 50% of the cost: All other radiographs, simple ex­tractions, fillings, denture coverage (full, partial, reline and repair), and crown repair. Dentures covered at 1 per 5 years, and relines and tissue conditioning covered at 1 per year.

MyTruAdvantage Choice (PPO) Optional supplemental benefits (OSB) are only available to members of MyTruAdvantage Choice (PPO) plan. Members of MyTruAdvantage plans that offer OSBs may enroll in OSBs at the time of MAPD enrollment or within two months of the MAPD plan’s effective date. Benefits may change on January 1 each year. Enrollees must use network providers for specific OSBs when stated in the Evidence of Coverage (EOC); otherwise, covered services may be received from non-network providers at a higher cost. Enrollees must continue to pay the Medicare Part B premium, their MyTruAdvantage plan premium and the OSB premium.


* Certain procedures, services and drugs may need advance approval from your plan. This is called a “prior authorization” or “preauthorization". Please refer to the plan’s Evidence of Coverage for all services that require Prior Authorization.