Martin’s Point Generations Advantage Select (PPO)
H1365 - 004 - 1
(4.5 / 5)
Martin’s Point Generations Advantage Select (PPO) is a Medicare Advantage (Part C) Plan by Martin’s Point Generations Advantage.
This page features plan details for 2023 Martin’s Point Generations Advantage Select (PPO) H1365 – 004 – 1 available in Aroo, Hanc, Kenn, Penob, Pisc, Some, Wash, Coos.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Martin’s Point Generations Advantage Select (PPO) is offered in the following locations.
Plan Overview
Martin’s Point Generations Advantage Select (PPO) offers the following coverage and cost-sharing.
| Insurer: | Martin’s Point Generations Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,700 In and Out-of-network $6,700 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $275.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Martin’s Point Generations Advantage Select (PPO) ?
Premium Breakdown
Martin’s Point Generations Advantage Select (PPO) has a monthly premium of $99.00. 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 |
|---|---|---|---|---|
| $164.90 | $48.20 | $50.80 | $0.00 | $263.90 |
- 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
Martin’s Point Generations Advantage Select (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $275.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
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 D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $50.80 | $43.00 | $35.20 | $27.50 | $19.70 |
Initial Coverage Phase
After you pay your $275.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $4.00 copay | $4.00 copay | |
| 2 (Generic) | $10.00 copay | $18.00 copay | $18.00 copay | |
| 3 (Preferred Brand) | $40.00 copay | $47.00 copay | $47.00 copay | |
| 4 (Non-Preferred Drug) | $95.00 copay | $100.00 copay | $100.00 copay | |
| 5 (Specialty Tier) | 28% | 28% | 28% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $12.00 copay | $10.00 copay | |
| 2 (Generic) | $30.00 copay | $54.00 copay | $45.00 copay | |
| 3 (Preferred Brand) | $120.00 copay | $141.00 copay | $117.50 copay | |
| 4 (Non-Preferred Drug) | $285.00 copay | $300.00 copay | $250.00 copay | |
| 5 (Specialty Tier) | 28% | 28% | 28% |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Martin’s Point Generations Advantage Select (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: Yes, contact plan for further details |
Dental (comprehensive)
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | Not covered (no limits) |
| Extractions: | Not covered (no limits) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | Not covered (no limits) |
Dental (preventive)
| Cleaning: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Cleaning: | Not covered (no limits) |
| Dental x-ray(s): | Not covered (no limits) |
| Dental x-ray(s): | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Not covered (no limits) |
| Office visit: | In-Network: $50.00 (authorization not required) (referral not required) |
| Office visit: | Out-of-Network: $50 copay or 50% coinsurance (authorization not required) (referral not required) |
| Oral exam: | Not covered (no limits) |
| Oral exam: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: 20% coinsurance (authorization required) (referral required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 30% coinsurance (authorization required) (referral required) |
| Diagnostic tests and procedures: | In-Network: 0-15% coinsurance (authorization required) (referral required) |
| Diagnostic tests and procedures: | Out-of-Network: 0-15% coinsurance (authorization required) (referral required) |
| Lab services: | In-Network: $0-5 copay or 0-20% coinsurance (authorization required) (referral required) |
| Lab services: | Out-of-Network: $0-5 copay or 0-20% coinsurance (authorization required) (referral required) |
| Outpatient x-rays: | In-Network: 15% coinsurance (authorization required) (referral required) |
| Outpatient x-rays: | Out-of-Network: 15% coinsurance (authorization required) (referral required) |
Doctor visits
| Primary: | In-Network: $0-10 copay per visit |
| Primary: | Out-of-Network: 30% coinsurance per visit |
| Specialist: | In-Network: $40 copay per visit (authorization not required) (referral required) |
| Specialist: | Out-of-Network: 30% coinsurance per visit (authorization not required) (referral required) |
Emergency care/Urgent care
| Emergency: | $95 copay per visit (always covered) |
| Urgent care: | $50 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $40 copay (authorization not required) (referral required) |
| Foot exams and treatment: | Out-of-Network: 30% coinsurance (authorization not required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $325 copay | |
| Out-of-Network: $325 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization not required) (referral required) |
| Fitting/evaluation: | Out-of-Network: $0-2,095 copay (limits may apply) (authorization not required) (referral required) |
| Hearing aids: | In-Network: $495-2,095 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | Out-of-Network: $0-2,095 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | In-Network: $40 copay (authorization not required) (referral required) |
| Hearing exam: | Out-of-Network: 30% coinsurance (authorization not required) (referral required) |
Hospital coverage (inpatient)
| In-Network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
| In-Network: $385 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
| Out-of-Network: 40% per day for days 1 and beyond (authorization required) (referral not required) |
Hospital coverage (outpatient)
| In-Network: $0-250 copay per visit (authorization required) (referral not required) | |
| In-Network: $0-275 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: 30% coinsurance per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $10,000 In and Out-of-network $6,700 In-network | |
| $6,700 In and Out-of-network $6,700 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay (authorization not required) |
| Diabetes supplies: | Out-of-Network: 20% coinsurance per item (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 30% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 30% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $220 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 30% per day for days 1 and beyond (authorization required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: 30% coinsurance (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | In-Network: $40 copay (authorization not required) (referral required) |
| Occupational therapy visit: | Out-of-Network: 30% coinsurance (authorization not required) (referral required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization not required) (referral required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 30% coinsurance (authorization not required) (referral required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) | |
| Out-of-Network: 30% per day for days 1 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | Out-of-Network: 30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Martin’s Point Generations Advantage Select (PPO) ?