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Independent Health’s Medicare Passport Connect (PPO)

H3344 - 013 - 0
4.5 out of 5 stars (4.5 / 5)

Independent Health’s Medicare Passport Connect (PPO) is a Medicare Advantage Plan by Independent Health.

This page features plan details for 2025 Independent Health’s Medicare Passport Connect (PPO) H3344 – 013 – 0 available in Western New York.

Locations

Independent Health’s Medicare Passport Connect (PPO) is offered in the following locations.

Allegany County, New York
Cattaraugus County, New York
Chautauqua County, New York

Click to see more locations

Plan Overview

Independent Health’s Medicare Passport Connect (PPO) offers the following coverage and cost-sharing.

Insurer:Independent Health
Health Plan Deductible:$0
MOOP:$10,100 In and Out-of-network
$6,750 In-network
Drugs Covered:Yes

Ready to sign up for Independent Health’s Medicare Passport Connect (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Independent Health’s Medicare Passport Connect (PPO) has a monthly premium of $72.30. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $72.30 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Independent Health’s Medicare Passport Connect (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $575.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$72.30$0.00

Initial Coverage Phase

After you pay your $575.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Independent Health’s Medicare Passport Connect (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Endodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – – Copay
    • Out-of-Network: No Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – – Copay
    • Out-of-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – – Copay
    • Out-of-Network: No Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – – Copay
    • Out-of-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $225 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Lab services
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-40 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $45 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Lab services
    • Out-of-Network: 50% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $40 copay per visit
  • Primary
    • Out-of-Network: 50% coinsurance per visit
  • Specialist
    • Out-of-Network: 50% coinsurance per visit

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $55 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $40 copay
    • Out-of-Network: 50% coinsurance
  • Routine foot care
    • Not covered

Ground ambulance

    • Out-of-Network: $300 copay
    • In-Network: $300 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • Out-of-Network: $45 copay
  • Hearing aids
    • In-Network: $499-1,949 copay
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $0-40 copay
  • Fitting/evaluation
    • In-Network: $45 copay
  • Hearing aids
    • Out-of-Network: $499-1,949 copay
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 50% coinsurance

Inpatient hospital coverage

    • In-Network: $325 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
    • Out-of-Network: 50% per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $10,100 In and Out-of-network
      $6,750 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 10-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 50% coinsurance per item

Medicare Part B drugs

  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 50% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $395 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $35 copay
    • Out-of-Network: 50% coinsurance
  • Outpatient individual therapy visit
    • In-Network: $35 copay
    • Out-of-Network: 50% coinsurance
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $35 copay
  • Inpatient hospital – psychiatric
    • Out-of-Network: 50% per stay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $35 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $400 copay per visit (Authorization Required)
    • Out-of-Network: 50% coinsurance per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: 50% coinsurance

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Occupational therapy visit
    • In-Network: $30 copay
    • Out-of-Network: 50% coinsurance
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 50% coinsurance (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 50% per stay (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • Out-of-Network: $0 copay
    • In-Network: $0 copay

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: $65 copay (Limits Apply)
  • Eyeglass lenses
    • Not covered
  • Other
    • Not covered
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Not covered
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Independent Health’s Medicare Passport Connect (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Independent Health’s Medicare Passport Connect (PPO)? See 2025 Independent Health’s Medicare Passport Connect (PPO) at MedicareAdvantageRX.com.

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